The New York State Senate

                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 4738--A

                       2017-2018 Regular Sessions

                          I N  A S S E M B L Y

                            February 3, 2017
                               ___________

Introduced by M. of A. GOTTFRIED, ABINANTI, BARRON, BENEDETTO, BICHOTTE,
  BLAKE,  BRONSON,  CARROLL,  COLTON,  COOK,  CRESPO, CYMBROWITZ, DILAN,
  DINOWITZ, ENGLEBRIGHT, GANTT, HIKIND, HUNTER, HYNDMAN, JAFFEE,  JENNE,
  JOYNER,  KIM,  LAVINE,  LIFTON,  LUPARDO, MAYER, M. G. MILLER, MOSLEY,
  PAULIN, PEOPLES-STOKES, PERRY, PICHARDO,  RAMOS,  RICHARDSON,  RIVERA,
  RODRIGUEZ, L. ROSENTHAL, SEAWRIGHT, SEPULVEDA, SIMOTAS, STECK, STIRPE,
  THIELE,  TITONE, TITUS, WALKER, WEINSTEIN, WEPRIN, DE LA ROSA, D'URSO,
  JEAN-PIERRE,  WRIGHT,  HARRIS,  WILLIAMS,  VANEL,  SOLAGES,   WALLACE,
  BARRETT,  PHEFFER AMATO,  NIOU,  ORTIZ, DICKENS, TAYLOR -- Multi-Spon-
  sored by -- M.  of A. ABBATE, ARROYO,  AUBRY,  CAHILL,  DAVILA,  FAHY,
  GLICK, GUNTHER, HOOPER, LENTOL, MAGEE, MAGNARELLI, O'DONNELL, PRETLOW,
  QUART,  ROZIC,  SIMON,  SKARTADOS  --  read  once  and referred to the
  Committee on Health -- recommitted  to  the  Committee  on  Health  in
  accordance  with Assembly Rule 3, sec. 2 -- committee discharged, bill
  amended, ordered reprinted as amended and recommitted to said  commit-
  tee

AN  ACT  to  amend  the  public health law and the state finance law, in
  relation to enacting the "New York health act" and to establishing New
  York Health

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Short  title. This act shall be known and may be cited as
the "New York health act".
  § 2. Legislative  findings  and  intent.  1.  The  state  constitution
states:  "The  protection and promotion of the health of the inhabitants
of the state are matters of public concern and provision therefor  shall
be made by the state and by such of its subdivisions and in such manner,
and by such means as the legislature shall from time to time determine."
(Article  XVII,  §3.)  The legislature finds and declares that all resi-
dents of the state have the right to health care.    While  the  federal
Affordable  Care Act brought many improvements in health care and health
coverage, it still leaves many New  Yorkers  without  coverage  or  with
inadequate  coverage.  New  Yorkers  -  as  individuals,  employers, and
taxpayers - have experienced a rise in  the  cost  of  health  care  and

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD09305-04-8

A. 4738--A                          2

coverage  in  recent  years,  including rising premiums, deductibles and
co-pays, restricted provider networks and high  out-of-network  charges.
Many New Yorkers go without health care because they cannot afford it or
suffer  financial  hardship to get it.  Businesses have also experienced
increases in the costs of health care benefits for their employees,  and
many  employers  are  shifting a larger share of the cost of coverage to
their employees or dropping coverage entirely.   Health  care  providers
are  also  affected  by  inadequate health coverage in New York state. A
large portion of hospitals, health centers and other providers now expe-
rience substantial losses due to the provision of care that is uncompen-
sated. Individuals often find that they are deprived of affordable  care
and  choice  because  of  decisions by health plans guided by the plan's
economic interests rather than the individual's health  care  needs.  To
address  the  fiscal  crisis facing the health care system and the state
and to assure New Yorkers can  exercise  their  right  to  health  care,
affordable  and comprehensive health coverage must be provided. Pursuant
to the state constitution's charge to the legislature to provide for the
health of New Yorkers, this legislation is an enactment of state concern
for the purpose of establishing  a  comprehensive  universal  guaranteed
health  care  coverage program and a health care cost control system for
the benefit of all residents of the state of New York.
  2. (a) It is the intent of the Legislature  to  create  the  New  York
Health program to provide a universal single payer health plan for every
New  Yorker, funded by broad-based revenue based on ability to pay.  The
state shall work to obtain waivers and other approvals relating to Medi-
caid, Child Health Plus, Medicare, the  Affordable  Care  Act,  and  any
other  appropriate federal programs, under which federal funds and other
subsidies that would otherwise be paid to New York State,  New  Yorkers,
and  health  care  providers for health coverage that will be equaled or
exceeded by New York Health will be paid by the  federal  government  to
New  York State and deposited in the New York Health trust fund, or paid
to health care providers and individuals in combination  with  New  York
Health trust fund payments, and for other program modifications (includ-
ing  elimination  of  cost  sharing and insurance premiums).  Under such
waivers and approvals, health coverage under those programs will, to the
maximum extent possible, be replaced and merged into  New  York  Health,
which will operate as a true single-payer program.
  (b)  If  any  necessary  waiver or approval is not obtained, the state
shall use state plan amendments and seek waivers and approvals to  maxi-
mize,  and  make  as  seamless as possible, the use of federally-matched
health programs and federal health programs in New York Health.    Thus,
even where other programs such as Medicaid or Medicare may contribute to
paying  for  care,  it is the goal of this legislation that the coverage
will be delivered by New York Health  and,  as  much  as  possible,  the
multiple  sources  of  funding will be pooled with other New York Health
funds and not be apparent to New York Health  members  or  participating
providers.
  (c)  This  program  will  promote  movement  away from fee-for-service
payment, which tends to reward quantity and requires excessive  adminis-
trative  expense,  and  towards alternate payment methodologies, such as
global or capitated payments to providers or health care  organizations,
that  promote  quality, efficiency, investment in primary and preventive
care, and innovation and integration in the organizing of health care.
  (d) The program shall promote the use of clinical data to improve  the
quality  of health care and public health, consistent with protection of

A. 4738--A                          3

patient confidentiality. The program shall maximize patient autonomy  in
choice of health care providers and health care decision making.
  3.  This  act  does  not  create  any  employment benefit, nor does it
require, prohibit, or limit the providing of any employment benefit.
  4. In order to promote improved quality of, and access to, health care
services and promote improved clinical outcomes, it is the policy of the
state to encourage cooperative, collaborative and  integrative  arrange-
ments  among  health  care providers who might otherwise be competitors,
under the active supervision of the commissioner of health.  It  is  the
intent  of  the state to supplant competition with such arrangements and
regulation only to the extent necessary to accomplish  the  purposes  of
this  act,  and  to  provide  state  action immunity under the state and
federal antitrust laws  to  health  care  providers,  particularly  with
respect  to  their  relations with the single-payer New York Health plan
created by this act.
  § 3. Article 50 and sections 5000, 5001, 5002 and 5003 of  the  public
health  law  are renumbered article 80 and sections 8000, 8001, 8002 and
8003, respectively, and a new article 51 is added to read as follows:
                               ARTICLE 51
                             NEW YORK HEALTH
SECTION 5100. DEFINITIONS.
        5101. PROGRAM CREATED.
        5102. BOARD OF TRUSTEES.
        5103. ELIGIBILITY AND ENROLLMENT.
        5104. BENEFITS.
        5105. HEALTH CARE PROVIDERS; CARE COORDINATION; PAYMENT  METHOD-
                OLOGIES.
        5106. HEALTH CARE ORGANIZATIONS.
        5107. PROGRAM STANDARDS.
        5108. REGULATIONS.
        5109. PROVISIONS RELATING TO FEDERAL HEALTH PROGRAMS.
        5110. ADDITIONAL PROVISIONS.
        5111. REGIONAL ADVISORY COUNCILS.
  §  5100.  DEFINITIONS.  AS  USED  IN THIS ARTICLE, THE FOLLOWING TERMS
SHALL HAVE THE FOLLOWING MEANINGS, UNLESS THE CONTEXT  CLEARLY  REQUIRES
OTHERWISE:
  1.  "BOARD" MEANS THE BOARD OF TRUSTEES OF THE NEW YORK HEALTH PROGRAM
CREATED BY SECTION FIFTY-ONE HUNDRED TWO OF THIS ARTICLE, AND  "TRUSTEE"
MEANS A TRUSTEE OF THE BOARD.
  2.  "CARE COORDINATION" MEANS, BUT IS NOT LIMITED TO, MANAGING, REFER-
RING TO, LOCATING, COORDINATING, AND MONITORING HEALTH CARE SERVICES FOR
THE MEMBER TO ASSURE THAT ALL MEDICALLY NECESSARY HEALTH  CARE  SERVICES
ARE MADE AVAILABLE TO AND ARE EFFECTIVELY USED BY THE MEMBER IN A TIMELY
MANNER,  CONSISTENT  WITH  PATIENT  AUTONOMY. CARE COORDINATION DOES NOT
INCLUDE A REQUIREMENT FOR PRIOR AUTHORIZATION FOR HEALTH  CARE  SERVICES
OR FOR REFERRAL FOR A MEMBER TO RECEIVE A HEALTH CARE SERVICE.
  3.  "CARE  COORDINATOR"  MEANS  AN  INDIVIDUAL  OR  ENTITY APPROVED TO
PROVIDE CARE COORDINATION UNDER SUBDIVISION  TWO  OF  SECTION  FIFTY-ONE
HUNDRED FIVE OF THIS ARTICLE.
  4. "FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM" MEANS THE MEDICAL ASSIST-
ANCE  PROGRAM  UNDER TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES
LAW, THE BASIC HEALTH PROGRAM UNDER SECTION THREE HUNDRED  SIXTY-NINE-GG
OF  THE  SOCIAL  SERVICES  LAW,  AND THE CHILD HEALTH PLUS PROGRAM UNDER
TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER.

A. 4738--A                          4

  5. "HEALTH CARE ORGANIZATION" MEANS AN ENTITY THAT IS APPROVED BY  THE
COMMISSIONER  UNDER  SECTION  FIFTY-ONE  HUNDRED  SIX OF THIS ARTICLE TO
PROVIDE HEALTH CARE SERVICES TO MEMBERS UNDER THE PROGRAM.
  6.  "HEALTH  CARE  PROVIDER"  MEANS  ANY  INDIVIDUAL OR ENTITY LEGALLY
AUTHORIZED TO PROVIDE A HEALTH CARE SERVICE UNDER MEDICAID  OR  MEDICARE
OR THIS ARTICLE. "HEALTH CARE PROFESSIONAL" MEANS A HEALTH CARE PROVIDER
THAT  IS  AN  INDIVIDUAL  LICENSED,  CERTIFIED,  REGISTERED OR OTHERWISE
AUTHORIZED TO PRACTICE UNDER TITLE EIGHT OF THE EDUCATION LAW TO PROVIDE
SUCH HEALTH CARE SERVICE, ACTING WITHIN HIS OR HER LAWFUL SCOPE OF PRAC-
TICE.
  7. "HEALTH CARE SERVICE" MEANS ANY HEALTH CARE SERVICE, INCLUDING CARE
COORDINATION, INCLUDED AS A BENEFIT UNDER THE PROGRAM.
  8. "IMPLEMENTATION PERIOD" MEANS THE PERIOD UNDER SUBDIVISION THREE OF
SECTION FIFTY-ONE HUNDRED ONE OF THIS ARTICLE DURING WHICH  THE  PROGRAM
WILL BE SUBJECT TO SPECIAL ELIGIBILITY AND FINANCING PROVISIONS UNTIL IT
IS FULLY IMPLEMENTED UNDER THAT SECTION.
  9.  "LONG  TERM  CARE"  MEANS  LONG TERM CARE, TREATMENT, MAINTENANCE,
SERVICES AND SUPPORTS, WITH THE EXCEPTION OF SHORT  TERM  REHABILITATION
AND SHORT TERM HOME CARE, AS DEFINED BY THE COMMISSIONER.
  10.  "MEDICAID"  OR "MEDICAL ASSISTANCE" MEANS TITLE ELEVEN OF ARTICLE
FIVE OF THE SOCIAL SERVICES LAW AND  THE  PROGRAM  THEREUNDER.    "CHILD
HEALTH  PLUS"  MEANS  TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER
AND THE PROGRAM THEREUNDER. "MEDICARE" MEANS TITLE XVIII OF THE  FEDERAL
SOCIAL  SECURITY ACT AND THE PROGRAMS THEREUNDER.  "AFFORDABLE CARE ACT"
MEANS THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT, PUBLIC LAW
111-148, AS AMENDED BY THE HEALTH CARE AND EDUCATION RECONCILIATION  ACT
OF  2010,  PUBLIC  LAW  111-152,  AND AS OTHERWISE AMENDED AND ANY REGU-
LATIONS OR GUIDANCE ISSUED THEREUNDER.   "BASIC  HEALTH  PROGRAM"  MEANS
SECTION  THREE  HUNDRED SIXTY-NINE-GG OF THE SOCIAL SERVICES LAW AND THE
PROGRAM THEREUNDER.
  11. "MEMBER" MEANS AN INDIVIDUAL WHO IS ENROLLED IN THE PROGRAM.
  12. "NEW YORK HEALTH", "NEW YORK HEALTH PROGRAM", AND  "PROGRAM"  MEAN
THE  NEW YORK HEALTH PROGRAM CREATED BY SECTION FIFTY-ONE HUNDRED ONE OF
THIS ARTICLE.
  13. "NEW YORK HEALTH TRUST FUND" MEANS THE NEW YORK HEALTH TRUST  FUND
ESTABLISHED UNDER SECTION EIGHTY-NINE-I OF THE STATE FINANCE LAW.
  14.  "OUT-OF-STATE  HEALTH  CARE  SERVICE" MEANS A HEALTH CARE SERVICE
PROVIDED TO A MEMBER WHILE THE MEMBER IS TEMPORARILY OUT  OF  THE  STATE
AND  (A)  IT  IS  MEDICALLY  NECESSARY  THAT  THE HEALTH CARE SERVICE BE
PROVIDED WHILE THE MEMBER IS OUT OF THE STATE, OR (B) IT  IS  CLINICALLY
APPROPRIATE  THAT  THE  HEALTH  CARE SERVICE BE PROVIDED BY A PARTICULAR
HEALTH CARE PROVIDER LOCATED OUT OF THE STATE RATHER THAN IN THE  STATE.
HOWEVER,  ANY HEALTH CARE SERVICE PROVIDED TO A NEW YORK HEALTH ENROLLEE
BY A HEALTH CARE PROVIDER QUALIFIED UNDER PARAGRAPH (A)  OF  SUBDIVISION
THREE  OF SECTION FIFTY-ONE HUNDRED FIVE OF THIS ARTICLE THAT IS LOCATED
OUTSIDE THE STATE SHALL NOT BE CONSIDERED AN  OUT-OF-STATE  SERVICE  AND
SHALL BE COVERED AS OTHERWISE PROVIDED IN THIS ARTICLE.
  15.  "PARTICIPATING PROVIDER" MEANS ANY INDIVIDUAL OR ENTITY THAT IS A
HEALTH CARE  PROVIDER  QUALIFIED  UNDER  SUBDIVISION  THREE  OF  SECTION
FIFTY-ONE  HUNDRED  FIVE  OF  THIS  ARTICLE  THAT  PROVIDES  HEALTH CARE
SERVICES TO MEMBERS UNDER THE PROGRAM, OR A HEALTH CARE ORGANIZATION.
  16. "PERSON" MEANS ANY INDIVIDUAL OR NATURAL PERSON,  TRUST,  PARTNER-
SHIP,  ASSOCIATION,  UNINCORPORATED  ASSOCIATION,  CORPORATION, COMPANY,
LIMITED LIABILITY COMPANY, PROPRIETORSHIP, JOINT  VENTURE,  FIRM,  JOINT
STOCK ASSOCIATION, DEPARTMENT, AGENCY, AUTHORITY, OR OTHER LEGAL ENTITY,
WHETHER FOR-PROFIT, NOT-FOR-PROFIT OR GOVERNMENTAL.

A. 4738--A                          5

  17. "PRESCRIPTION AND NON-PRESCRIPTION DRUGS" MEANS PRESCRIPTION DRUGS
AS DEFINED IN SECTION TWO HUNDRED SEVENTY OF THIS CHAPTER, AND NON-PRES-
CRIPTION SMOKING CESSATION PRODUCTS OR DEVICES.
  18.  "RESIDENT" MEANS AN INDIVIDUAL WHOSE PRIMARY PLACE OF ABODE IS IN
THE STATE, WITHOUT REGARD TO THE  INDIVIDUAL'S  IMMIGRATION  STATUS,  AS
DETERMINED ACCORDING TO REGULATIONS OF THE COMMISSIONER.
  §  5101.  PROGRAM  CREATED.  1.  THE NEW YORK HEALTH PROGRAM IS HEREBY
CREATED IN THE DEPARTMENT. THE COMMISSIONER SHALL ESTABLISH  AND  IMPLE-
MENT  THE  PROGRAM UNDER THIS ARTICLE. THE PROGRAM SHALL PROVIDE COMPRE-
HENSIVE HEALTH COVERAGE TO EVERY RESIDENT WHO ENROLLS IN THE PROGRAM.
  2. THE COMMISSIONER SHALL, TO THE MAXIMUM EXTENT  POSSIBLE,  ORGANIZE,
ADMINISTER AND MARKET THE PROGRAM AND SERVICES AS A SINGLE PROGRAM UNDER
THE  NAME "NEW YORK HEALTH" OR SUCH OTHER NAME AS THE COMMISSIONER SHALL
DETERMINE, REGARDLESS OF UNDER WHICH LAW OR SOURCE THE DEFINITION  OF  A
BENEFIT  IS  FOUND INCLUDING (ON A VOLUNTARY BASIS) RETIREE HEALTH BENE-
FITS. IN IMPLEMENTING THIS ARTICLE, THE COMMISSIONER SHALL  AVOID  JEOP-
ARDIZING  FEDERAL  FINANCIAL  PARTICIPATION  IN THESE PROGRAMS AND SHALL
TAKE CARE TO PROMOTE PUBLIC UNDERSTANDING  AND  AWARENESS  OF  AVAILABLE
BENEFITS AND PROGRAMS.
  3. THE COMMISSIONER SHALL DETERMINE WHEN INDIVIDUALS MAY BEGIN ENROLL-
ING IN THE PROGRAM. THERE SHALL BE AN IMPLEMENTATION PERIOD, WHICH SHALL
BEGIN  ON  THE  DATE THAT INDIVIDUALS MAY BEGIN ENROLLING IN THE PROGRAM
AND SHALL END AS DETERMINED BY THE COMMISSIONER.
  4. AN INSURER AUTHORIZED TO PROVIDE COVERAGE PURSUANT TO THE INSURANCE
LAW OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED  UNDER  THIS  CHAPTER
MAY,  IF  OTHERWISE  AUTHORIZED,  OFFER  BENEFITS  THAT DO NOT COVER ANY
SERVICE FOR WHICH COVERAGE IS OFFERED TO INDIVIDUALS UNDER THE  PROGRAM,
BUT  MAY NOT OFFER BENEFITS THAT COVER ANY SERVICE FOR WHICH COVERAGE IS
OFFERED TO INDIVIDUALS UNDER THE PROGRAM. PROVIDED, HOWEVER,  THAT  THIS
SUBDIVISION  SHALL  NOT  PROHIBIT (A) THE OFFERING OF ANY BENEFITS TO OR
FOR INDIVIDUALS, INCLUDING THEIR FAMILIES, WHO ARE EMPLOYED OR  SELF-EM-
PLOYED  IN  THE STATE BUT WHO ARE NOT RESIDENTS OF THE STATE, OR (B) THE
OFFERING OF BENEFITS DURING THE IMPLEMENTATION PERIOD TO INDIVIDUALS WHO
ENROLLED OR MAY ENROLL AS MEMBERS OF THE PROGRAM, OR (C) THE OFFERING OF
RETIREE HEALTH BENEFITS.
  5. A COLLEGE, UNIVERSITY OR OTHER INSTITUTION OF HIGHER  EDUCATION  IN
THE  STATE  MAY  PURCHASE COVERAGE UNDER THE PROGRAM FOR ANY STUDENT, OR
STUDENT'S DEPENDENT, WHO IS NOT A RESIDENT OF THE STATE.
  6. TO THE EXTENT ANY PROVISION OF THIS CHAPTER,  THE  SOCIAL  SERVICES
LAW, THE INSURANCE LAW OR THE ELDER LAW:
  (A) IS INCONSISTENT WITH ANY PROVISION OF THIS ARTICLE OR THE LEGISLA-
TIVE  INTENT  OF  THE  NEW YORK HEALTH ACT, THIS ARTICLE SHALL APPLY AND
PREVAIL, EXCEPT WHERE EXPLICITLY PROVIDED OTHERWISE BY THIS ARTICLE; AND
  (B) IS CONSISTENT WITH THE PROVISIONS OF THIS ARTICLE AND THE LEGISLA-
TIVE INTENT OF THE NEW YORK HEALTH ACT, THE PROVISION OF THAT LAW  SHALL
APPLY.
  7.  THE  PROGRAM SHALL BE DEEMED TO BE A HEALTH CARE PLAN FOR PURPOSES
OF UTILIZATION REVIEW AND EXTERNAL APPEAL UNDER  ARTICLE  FORTY-NINE  OF
THIS CHAPTER.
  8.  NO  MEMBER  SHALL  BE  REQUIRED TO RECEIVE ANY HEALTH CARE SERVICE
THROUGH ANY ENTITY ORGANIZED, CERTIFIED OR  OPERATING  UNDER  GUIDELINES
UNDER  ARTICLE  FORTY-FOUR  OF  THIS CHAPTER, OR SPECIFIED UNDER SECTION
THREE HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW, THE INSURANCE LAW
OR THE ELDER LAW. NO SUCH ENTITY SHALL RECEIVE PAYMENT FOR  HEALTH  CARE
SERVICES (OTHER THAN CARE COORDINATION) FROM THE PROGRAM.  HOWEVER, THIS
SUBDIVISION  SHALL  NOT  PRECLUDE  THE  USE  OF  A MEDICARE MANAGED CARE

A. 4738--A                          6

("MEDICARE ADVANTAGE") ENTITY UNDER THE PROGRAM AND OTHERWISE CONSISTENT
WITH THIS ARTICLE.
  9.  THE  PROGRAM  SHALL  INCLUDE  PROVISION FOR AN APPROPRIATE RESERVE
FUND.
  § 5102. BOARD OF TRUSTEES. 1. THE NEW YORK HEALTH BOARD OF TRUSTEES IS
HEREBY CREATED IN THE DEPARTMENT. THE BOARD OF TRUSTEES  SHALL,  AT  THE
REQUEST  OF  THE  COMMISSIONER,  CONSIDER  ANY  MATTER TO EFFECTUATE THE
PROVISIONS AND PURPOSES OF THIS ARTICLE, AND MAY ADVISE THE COMMISSIONER
THEREON; AND IT MAY, FROM TIME TO TIME, SUBMIT TO THE  COMMISSIONER  ANY
RECOMMENDATIONS  TO EFFECTUATE THE PROVISIONS AND PURPOSES OF THIS ARTI-
CLE. THE COMMISSIONER MAY PROPOSE REGULATIONS  UNDER  THIS  ARTICLE  AND
AMENDMENTS THERETO FOR CONSIDERATION BY THE BOARD. THE BOARD OF TRUSTEES
SHALL  HAVE  NO EXECUTIVE, ADMINISTRATIVE OR APPOINTIVE DUTIES EXCEPT AS
OTHERWISE PROVIDED BY LAW. THE BOARD OF TRUSTEES  SHALL  HAVE  POWER  TO
ESTABLISH,  AND  FROM  TIME TO TIME, AMEND REGULATIONS TO EFFECTUATE THE
PROVISIONS AND PURPOSES OF THIS ARTICLE,  SUBJECT  TO  APPROVAL  BY  THE
COMMISSIONER.
  2. THE BOARD SHALL BE COMPOSED OF:
  (A)  THE  COMMISSIONER,  THE SUPERINTENDENT OF FINANCIAL SERVICES, AND
THE DIRECTOR OF THE BUDGET, OR THEIR DESIGNEES, AS EX OFFICIO MEMBERS;
  (B) TWENTY-SIX TRUSTEES APPOINTED BY THE GOVERNOR;
  (I) SIX OF WHOM SHALL BE REPRESENTATIVES OF HEALTH CARE CONSUMER ADVO-
CACY ORGANIZATIONS WHICH HAVE A STATEWIDE OR REGIONAL CONSTITUENCY,  WHO
HAVE BEEN INVOLVED IN ACTIVITIES RELATED TO HEALTH CARE CONSUMER ADVOCA-
CY,  INCLUDING  ISSUES  OF INTEREST TO LOW- AND MODERATE-INCOME INDIVID-
UALS;
  (II) TWO OF WHOM SHALL BE REPRESENTATIVES  OF  PROFESSIONAL  ORGANIZA-
TIONS REPRESENTING PHYSICIANS;
  (III)  TWO  OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL ORGANIZA-
TIONS REPRESENTING LICENSED  OR  REGISTERED  HEALTH  CARE  PROFESSIONALS
OTHER THAN PHYSICIANS;
  (IV)  THREE OF WHOM SHALL BE REPRESENTATIVES OF GENERAL HOSPITALS, ONE
OF WHOM SHALL BE A REPRESENTATIVE OF PUBLIC GENERAL HOSPITALS;
  (V) ONE OF WHOM SHALL BE A REPRESENTATIVE OF COMMUNITY HEALTH CENTERS;
  (VI) TWO OF WHOM SHALL BE REPRESENTATIVES OF  REHABILITATION  OR  HOME
CARE PROVIDERS;
  (VII)  TWO  OF  WHOM  SHALL BE REPRESENTATIVES OF BEHAVIORAL OR MENTAL
HEALTH OR DISABILITY SERVICE PROVIDERS;
  (VIII) TWO OF WHOM SHALL BE REPRESENTATIVES OF HEALTH  CARE  ORGANIZA-
TIONS;
  (IX) TWO OF WHOM SHALL BE REPRESENTATIVES OF ORGANIZED LABOR;
  (X)  TWO  OF  WHOM  SHALL  HAVE  DEMONSTRATED EXPERTISE IN HEALTH CARE
FINANCE; AND
  (XI) TWO OF WHOM SHALL BE EMPLOYERS OR  REPRESENTATIVES  OF  EMPLOYERS
WHO  PAY THE PAYROLL TAX UNDER THIS ARTICLE, OR, PRIOR TO THE TAX BECOM-
ING EFFECTIVE, WILL PAY THE TAX;
  (C) FOURTEEN TRUSTEES APPOINTED BY THE GOVERNOR; FIVE OF  WHOM  TO  BE
APPOINTED  ON THE RECOMMENDATION OF THE SPEAKER OF THE ASSEMBLY; FIVE OF
WHOM TO BE APPOINTED ON THE RECOMMENDATION OF THE TEMPORARY PRESIDENT OF
THE SENATE; TWO OF WHOM TO BE APPOINTED ON  THE  RECOMMENDATION  OF  THE
MINORITY  LEADER OF THE ASSEMBLY; AND TWO OF WHOM TO BE APPOINTED ON THE
RECOMMENDATION OF THE MINORITY LEADER OF THE SENATE.
  3. AFTER THE END OF THE IMPLEMENTATION PERIOD, NO PERSON  SHALL  BE  A
TRUSTEE UNLESS HE OR SHE IS A MEMBER OF THE PROGRAM, EXCEPT THE EX OFFI-
CIO TRUSTEES. EACH TRUSTEE SHALL SERVE AT THE PLEASURE OF THE APPOINTING
OFFICER, EXCEPT THE EX OFFICIO TRUSTEES.

A. 4738--A                          7

  4.  THE  CHAIR  OF THE BOARD SHALL BE APPOINTED, AND MAY BE REMOVED AS
CHAIR, BY THE GOVERNOR FROM AMONG THE TRUSTEES. THE BOARD SHALL MEET  AT
LEAST  FOUR  TIMES  EACH  CALENDAR YEAR. MEETINGS SHALL BE HELD UPON THE
CALL OF THE CHAIR AND AS PROVIDED  BY  THE  BOARD.  A  MAJORITY  OF  THE
APPOINTED  TRUSTEES  SHALL BE A QUORUM OF THE BOARD, AND THE AFFIRMATIVE
VOTE OF A MAJORITY OF THE TRUSTEES VOTING, BUT NOT LESS THAN TEN,  SHALL
BE  NECESSARY  FOR  ANY  ACTION  TO BE TAKEN BY THE BOARD. THE BOARD MAY
ESTABLISH AN EXECUTIVE COMMITTEE TO EXERCISE ANY POWERS OR DUTIES OF THE
BOARD AS IT MAY PROVIDE, AND OTHER COMMITTEES TO ASSIST THE BOARD OR THE
EXECUTIVE COMMITTEE. THE CHAIR OF THE BOARD SHALL  CHAIR  THE  EXECUTIVE
COMMITTEE  AND  SHALL APPOINT THE CHAIR AND MEMBERS OF ALL OTHER COMMIT-
TEES. THE BOARD OF TRUSTEES MAY APPOINT ONE OR MORE ADVISORY COMMITTEES.
MEMBERS OF ADVISORY COMMITTEES NEED NOT BE MEMBERS OF THE BOARD OF TRUS-
TEES.
  5. TRUSTEES SHALL SERVE WITHOUT COMPENSATION BUT SHALL  BE  REIMBURSED
FOR  THEIR  NECESSARY  AND ACTUAL EXPENSES INCURRED WHILE ENGAGED IN THE
BUSINESS OF THE BOARD.
  6. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, NO OFFICER OR
EMPLOYEE OF THE STATE OR ANY LOCAL GOVERNMENT SHALL FORFEIT OR BE DEEMED
TO HAVE FORFEITED HIS OR HER OFFICE OR EMPLOYMENT BY REASON OF  BEING  A
TRUSTEE.
  7.  THE  BOARD  AND ITS COMMITTEES AND ADVISORY COMMITTEES MAY REQUEST
AND RECEIVE THE ASSISTANCE OF THE DEPARTMENT  AND  ANY  OTHER  STATE  OR
LOCAL GOVERNMENTAL ENTITY IN EXERCISING ITS POWERS AND DUTIES.
  8. NO LATER THAN TWO YEARS AFTER THE EFFECTIVE DATE OF THIS ARTICLE:
  (A) THE BOARD SHALL DEVELOP A PROPOSAL, CONSISTENT WITH THE PRINCIPLES
OF  THIS  ARTICLE, FOR PROVISION BY THE PROGRAM OF LONG-TERM CARE COVER-
AGE, INCLUDING THE DEVELOPMENT OF A PROPOSAL, CONSISTENT WITH THE  PRIN-
CIPLES  OF  THIS  ARTICLE, FOR ITS FUNDING.  IN DEVELOPING THE PROPOSAL,
THE BOARD SHALL CONSULT WITH AN ADVISORY  COMMITTEE,  APPOINTED  BY  THE
CHAIR OF THE BOARD, INCLUDING REPRESENTATIVES OF CONSUMERS AND POTENTIAL
CONSUMERS  OF  LONG-TERM  CARE,  PROVIDERS OF LONG-TERM CARE, LABOR, AND
OTHER INTERESTED PARTIES. THE BOARD SHALL PRESENT ITS  PROPOSAL  TO  THE
GOVERNOR AND THE LEGISLATURE.
  (B)  THE  BOARD SHALL DEVELOP PROPOSALS FOR: (I) INCORPORATING RETIREE
HEALTH BENEFITS INTO NEW YORK HEALTH; (II) ACCOMMODATING EMPLOYER  RETI-
REE  HEALTH BENEFITS FOR PEOPLE WHO HAVE BEEN MEMBERS OF NEW YORK HEALTH
BUT LIVE AS RETIREES OUT OF THE STATE; AND (III) ACCOMMODATING  EMPLOYER
RETIREE  HEALTH  BENEFITS FOR PEOPLE WHO EARNED OR ACCRUED SUCH BENEFITS
WHILE RESIDING IN THE STATE PRIOR TO  THE  IMPLEMENTATION  OF  NEW  YORK
HEALTH  AND  LIVE AS RETIREES OUT OF THE STATE.  THE BOARD SHALL PRESENT
ITS PROPOSALS TO THE GOVERNOR AND THE LEGISLATURE.
  (C) THE BOARD SHALL DEVELOP A PROPOSAL FOR NEW YORK HEALTH COVERAGE OF
HEALTH CARE  SERVICES  COVERED  UNDER  THE  WORKERS'  COMPENSATION  LAW,
INCLUDING  WHETHER  AND HOW TO CONTINUE FUNDING FOR THOSE SERVICES UNDER
THAT LAW AND WHETHER AND HOW TO INCORPORATE  AN  ELEMENT  OF  EXPERIENCE
RATING.
  §  5103.  ELIGIBILITY  AND  ENROLLMENT. 1. EVERY RESIDENT OF THE STATE
SHALL BE ELIGIBLE AND ENTITLED TO ENROLL AS A MEMBER UNDER THE PROGRAM.
  2. NO INDIVIDUAL SHALL BE REQUIRED TO PAY ANY PREMIUM OR OTHER  CHARGE
FOR ENROLLING IN OR BEING A MEMBER UNDER THE PROGRAM.
  3.  A  NEWBORN  CHILD  SHALL BE ENROLLED AS OF THE DATE OF THE CHILD'S
BIRTH IF ENROLLMENT IS DONE PRIOR TO THE CHILD'S BIRTH OR  WITHIN  SIXTY
DAYS AFTER THE CHILD'S BIRTH.
  §  5104.  BENEFITS.  1. THE PROGRAM SHALL PROVIDE COMPREHENSIVE HEALTH
COVERAGE TO EVERY MEMBER, WHICH SHALL INCLUDE ALL HEALTH  CARE  SERVICES

A. 4738--A                          8

REQUIRED  TO  BE  COVERED  UNDER ANY OF THE FOLLOWING, WITHOUT REGARD TO
WHETHER THE MEMBER WOULD OTHERWISE BE ELIGIBLE FOR  OR  COVERED  BY  THE
PROGRAM OR SOURCE REFERRED TO:
  (A) CHILD HEALTH PLUS;
  (B) MEDICAID;
  (C) MEDICARE;
  (D)  ARTICLE  FORTY-FOUR  OF  THIS  CHAPTER  OR  ARTICLE THIRTY-TWO OR
FORTY-THREE OF THE INSURANCE LAW;
  (E) ARTICLE ELEVEN OF THE CIVIL SERVICE LAW, AS OF THE DATE  ONE  YEAR
BEFORE THE BEGINNING OF THE IMPLEMENTATION PERIOD;
  (F)  ANY  COST  INCURRED DEFINED IN PARAGRAPH ONE OF SUBSECTION (A) OF
SECTION FIFTY-ONE HUNDRED TWO OF THE INSURANCE LAW, PROVIDED  THAT  THIS
COVERAGE  SHALL  NOT  REPLACE  COVERAGE  UNDER  ARTICLE FIFTY-ONE OF THE
INSURANCE LAW; AND
  (G) ANY ADDITIONAL HEALTH CARE SERVICE AUTHORIZED TO BE ADDED  TO  THE
PROGRAM'S BENEFITS BY THE PROGRAM;
  (H)  PROVIDED  THAT  NONE  OF  THE ABOVE SHALL INCLUDE LONG TERM CARE,
UNTIL A PROPOSAL UNDER PARAGRAPH (A) OF  SUBDIVISION  EIGHT  OF  SECTION
FIFTY-ONE HUNDRED TWO OF THIS ARTICLE IS ENACTED INTO LAW.
  2. NO MEMBER SHALL BE REQUIRED TO PAY ANY PREMIUM, DEDUCTIBLE, CO-PAY-
MENT OR CO-INSURANCE UNDER THE PROGRAM.
  3. THE PROGRAM SHALL PROVIDE FOR PAYMENT UNDER THE PROGRAM FOR:
  (A)  EMERGENCY AND TEMPORARY HEALTH CARE SERVICES PROVIDED TO A MEMBER
OR INDIVIDUAL ENTITLED TO BECOME A MEMBER WHO HAS NOT HAD  A  REASONABLE
OPPORTUNITY TO BECOME A MEMBER OR TO ENROLL WITH A CARE COORDINATOR; AND
  (B) HEALTH CARE SERVICES PROVIDED IN AN EMERGENCY TO AN INDIVIDUAL WHO
IS  ENTITLED  TO  BECOME  A  MEMBER OR ENROLLED WITH A CARE COORDINATOR,
REGARDLESS OF HAVING HAD AN OPPORTUNITY TO DO SO.
  § 5105. HEALTH CARE PROVIDERS; CARE  COORDINATION;  PAYMENT  METHODOL-
OGIES.   1. CHOICE OF HEALTH CARE PROVIDER. (A) ANY HEALTH CARE PROVIDER
QUALIFIED TO PARTICIPATE UNDER THIS  SECTION  MAY  PROVIDE  HEALTH  CARE
SERVICES  UNDER  THE  PROGRAM, PROVIDED THAT THE HEALTH CARE PROVIDER IS
OTHERWISE LEGALLY AUTHORIZED TO PERFORM THE HEALTH CARE SERVICE FOR  THE
INDIVIDUAL AND UNDER THE CIRCUMSTANCES INVOLVED.
  (B)  A  MEMBER  MAY  CHOOSE  TO RECEIVE HEALTH CARE SERVICES UNDER THE
PROGRAM FROM ANY PARTICIPATING PROVIDER, CONSISTENT WITH  PROVISIONS  OF
THIS  ARTICLE  RELATING  TO  CARE COORDINATION AND HEALTH CARE ORGANIZA-
TIONS, THE WILLINGNESS OR  AVAILABILITY  OF  THE  PROVIDER  (SUBJECT  TO
PROVISIONS  OF  THIS ARTICLE RELATING TO DISCRIMINATION), AND THE APPRO-
PRIATE CLINICALLY-RELEVANT CIRCUMSTANCES.
  2. CARE COORDINATION. (A) A CARE COORDINATOR MAY BE AN  INDIVIDUAL  OR
ENTITY THAT IS APPROVED BY THE PROGRAM THAT IS:
  (I)  A  HEALTH CARE PRACTITIONER WHO IS: (A) THE MEMBER'S PRIMARY CARE
PRACTITIONER; (B) AT THE OPTION OF A FEMALE MEMBER, THE MEMBER'S PROVID-
ER OF PRIMARY GYNECOLOGICAL CARE; OR (C) AT THE OPTION OF A  MEMBER  WHO
HAS  A  CHRONIC  CONDITION  THAT  REQUIRES  SPECIALTY CARE, A SPECIALIST
HEALTH CARE PRACTITIONER WHO REGULARLY AND CONTINUALLY  PROVIDES  TREAT-
MENT FOR THAT CONDITION TO THE MEMBER;
  (II)  AN ENTITY LICENSED UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR
CERTIFIED UNDER ARTICLE THIRTY-SIX OF THIS CHAPTER, OR, WITH RESPECT  TO
A  MEMBER  WHO  RECEIVES  CHRONIC MENTAL HEALTH CARE SERVICES, AN ENTITY
LICENSED UNDER ARTICLE THIRTY-ONE OF THE MENTAL  HYGIENE  LAW  OR  OTHER
ENTITY APPROVED BY THE COMMISSIONER IN CONSULTATION WITH THE COMMISSION-
ER OF MENTAL HEALTH;
  (III) A HEALTH CARE ORGANIZATION;

A. 4738--A                          9

  (IV) A TAFT-HARTLEY FUND, WITH RESPECT TO ITS MEMBERS AND THEIR FAMILY
MEMBERS;  PROVIDED THAT THIS PROVISION SHALL NOT PRECLUDE A TAFT-HARTLEY
FUND FROM BECOMING A CARE COORDINATOR UNDER  SUBPARAGRAPH  (V)  OF  THIS
PARAGRAPH  OR A HEALTH CARE ORGANIZATION UNDER SECTION FIFTY-ONE HUNDRED
SIX OF THIS ARTICLE; OR
  (V) ANY NOT-FOR-PROFIT OR GOVERNMENTAL ENTITY APPROVED BY THE PROGRAM.
  (B)(I)  EVERY  MEMBER SHALL ENROLL WITH A CARE COORDINATOR THAT AGREES
TO PROVIDE CARE COORDINATION TO THE MEMBER  PRIOR  TO  RECEIVING  HEALTH
CARE  SERVICES  TO  BE PAID FOR UNDER THE PROGRAM.  HEALTH CARE SERVICES
PROVIDED TO A MEMBER SHALL NOT BE SUBJECT TO PAYMENT UNDER  THE  PROGRAM
UNLESS  THE  MEMBER  IS ENROLLED WITH A CARE COORDINATOR AT THE TIME THE
HEALTH CARE SERVICE IS PROVIDED.
  (II) THIS PARAGRAPH SHALL NOT APPLY TO HEALTH CARE  SERVICES  PROVIDED
UNDER  SUBDIVISION THREE OF SECTION FIFTY-ONE HUNDRED FOUR OF THIS ARTI-
CLE.
  (III) THE MEMBER SHALL REMAIN  ENROLLED  WITH  THAT  CARE  COORDINATOR
UNTIL  THE  MEMBER BECOMES ENROLLED WITH A DIFFERENT CARE COORDINATOR OR
CEASES TO BE A MEMBER. MEMBERS HAVE THE RIGHT TO CHANGE THEIR CARE COOR-
DINATOR ON TERMS AT LEAST AS PERMISSIVE AS  THE  PROVISIONS  OF  SECTION
THREE  HUNDRED  SIXTY-FOUR-J  OF  THE SOCIAL SERVICES LAW RELATING TO AN
INDIVIDUAL CHANGING HIS OR HER PRIMARY CARE  PROVIDER  OR  MANAGED  CARE
PROVIDER.
  (C)  CARE COORDINATION SHALL BE PROVIDED TO THE MEMBER BY THE MEMBER'S
CARE COORDINATOR.  A CARE COORDINATOR MAY EMPLOY OR UTILIZE THE SERVICES
OF OTHER INDIVIDUALS OR ENTITIES TO ASSIST  IN  PROVIDING  CARE  COORDI-
NATION FOR THE MEMBER, CONSISTENT WITH REGULATIONS OF THE COMMISSIONER.
  (D)  A  HEALTH  CARE ORGANIZATION MAY ESTABLISH RULES RELATING TO CARE
COORDINATION FOR MEMBERS IN THE HEALTH CARE ORGANIZATION, DIFFERENT FROM
THIS SUBDIVISION BUT OTHERWISE CONSISTENT WITH THIS  ARTICLE  AND  OTHER
APPLICABLE LAWS.
  (E) THE COMMISSIONER SHALL DEVELOP AND IMPLEMENT PROCEDURES AND STAND-
ARDS FOR AN INDIVIDUAL OR ENTITY TO BE APPROVED TO BE A CARE COORDINATOR
IN  THE  PROGRAM,  INCLUDING BUT NOT LIMITED TO PROCEDURES AND STANDARDS
RELATING TO THE REVOCATION,  SUSPENSION,  LIMITATION,  OR  ANNULMENT  OF
APPROVAL  ON A DETERMINATION THAT THE INDIVIDUAL OR ENTITY IS NOT COMPE-
TENT TO BE A CARE COORDINATOR OR HAS EXHIBITED A COURSE OF CONDUCT WHICH
IS EITHER INCONSISTENT WITH PROGRAM STANDARDS AND REGULATIONS  OR  WHICH
EXHIBITS  AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR IS
A POTENTIAL THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH  PROCEDURES  AND
STANDARDS  SHALL  NOT  LIMIT  APPROVAL  TO  BE A CARE COORDINATOR IN THE
PROGRAM FOR ECONOMIC PURPOSES AND SHALL BE CONSISTENT WITH GOOD  PROFES-
SIONAL PRACTICE. IN DEVELOPING THE PROCEDURES AND STANDARDS, THE COMMIS-
SIONER  SHALL:  (I)  CONSIDER  EXISTING  STANDARDS DEVELOPED BY NATIONAL
ACCREDITING  AND  PROFESSIONAL  ORGANIZATIONS;  AND  (II)  CONSULT  WITH
NATIONAL AND LOCAL ORGANIZATIONS WORKING ON CARE COORDINATION OR SIMILAR
MODELS,  INCLUDING  HEALTH  CARE  PRACTITIONERS, HOSPITALS, CLINICS, AND
CONSUMERS AND THEIR REPRESENTATIVES. WHEN  DEVELOPING  AND  IMPLEMENTING
STANDARDS  OF  APPROVAL  OF  CARE COORDINATORS FOR INDIVIDUALS RECEIVING
CHRONIC MENTAL HEALTH CARE SERVICES, THE COMMISSIONER SHALL CONSULT WITH
THE COMMISSIONER OF MENTAL HEALTH. AN INDIVIDUAL OR ENTITY MAY NOT BE  A
CARE  COORDINATOR  UNLESS THE SERVICES INCLUDED IN CARE COORDINATION ARE
WITHIN THE INDIVIDUAL'S PROFESSIONAL SCOPE OF PRACTICE OR  THE  ENTITY'S
LEGAL AUTHORITY.
  (F)  TO  MAINTAIN APPROVAL UNDER THE PROGRAM, A CARE COORDINATOR MUST:
(I) RENEW ITS STATUS AT A FREQUENCY DETERMINED BY THE COMMISSIONER;  AND
(II)  PROVIDE  DATA TO THE DEPARTMENT AS REQUIRED BY THE COMMISSIONER TO

A. 4738--A                         10

ENABLE THE COMMISSIONER TO EVALUATE THE IMPACT OF CARE  COORDINATORS  ON
QUALITY, OUTCOMES AND COST.
  (G)  NOTHING  IN  THIS  SUBDIVISION  SHALL AUTHORIZE ANY INDIVIDUAL TO
ENGAGE IN ANY ACT IN VIOLATION OF TITLE EIGHT OF THE EDUCATION LAW.
  3. HEALTH CARE PROVIDERS. (A) THE  COMMISSIONER  SHALL  ESTABLISH  AND
MAINTAIN PROCEDURES AND STANDARDS FOR HEALTH CARE PROVIDERS TO BE QUALI-
FIED  TO PARTICIPATE IN THE PROGRAM, INCLUDING BUT NOT LIMITED TO PROCE-
DURES AND STANDARDS RELATING TO THE REVOCATION, SUSPENSION,  LIMITATION,
OR ANNULMENT OF QUALIFICATION TO PARTICIPATE ON A DETERMINATION THAT THE
HEALTH  CARE  PROVIDER  IS  NOT  COMPETENT  TO BE A PROVIDER OF SPECIFIC
HEALTH CARE SERVICES OR HAS EXHIBITED  A  COURSE  OF  CONDUCT  WHICH  IS
EITHER  INCONSISTENT  WITH  PROGRAM  STANDARDS  AND REGULATIONS OR WHICH
EXHIBITS AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR  IS
A  POTENTIAL  THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH PROCEDURES AND
STANDARDS SHALL NOT LIMIT HEALTH  CARE  PROVIDER  PARTICIPATION  IN  THE
PROGRAM  FOR ECONOMIC PURPOSES AND SHALL BE CONSISTENT WITH GOOD PROFES-
SIONAL PRACTICE.  SUCH PROCEDURES AND STANDARDS  MAY  BE  DIFFERENT  FOR
DIFFERENT  TYPES OF HEALTH CARE PROVIDERS AND HEALTH CARE PROFESSIONALS.
ANY HEALTH CARE PROVIDER WHO IS QUALIFIED TO PARTICIPATE UNDER MEDICAID,
CHILD HEALTH PLUS OR MEDICARE SHALL BE DEEMED TO BE QUALIFIED TO PARTIC-
IPATE IN THE PROGRAM, AND ANY HEALTH CARE PROVIDER'S REVOCATION, SUSPEN-
SION, LIMITATION, OR ANNULMENT OF QUALIFICATION TO PARTICIPATE IN ANY OF
THOSE PROGRAMS SHALL APPLY TO THE HEALTH CARE  PROVIDER'S  QUALIFICATION
TO  PARTICIPATE  IN  THE  PROGRAM;  PROVIDED THAT A HEALTH CARE PROVIDER
QUALIFIED UNDER THIS SENTENCE SHALL  FOLLOW  THE  PROCEDURES  TO  BECOME
QUALIFIED UNDER THE PROGRAM BY THE END OF THE IMPLEMENTATION PERIOD.
  (B) THE COMMISSIONER SHALL ESTABLISH AND MAINTAIN PROCEDURES AND STAN-
DARDS FOR RECOGNIZING HEALTH CARE PROVIDERS LOCATED OUT OF THE STATE FOR
PURPOSES OF PROVIDING COVERAGE UNDER THE PROGRAM FOR OUT-OF-STATE HEALTH
CARE SERVICES.
  (C)  PROCEDURES  AND  STANDARDS  UNDER  THIS SUBDIVISION SHALL INCLUDE
PROVISIONS FOR EXPEDITED TEMPORARY QUALIFICATION TO PARTICIPATE  IN  THE
PROGRAM FOR HEALTH CARE PROFESSIONALS WHO ARE (I) TEMPORARILY AUTHORIZED
TO  PRACTICE  IN  THE STATE OR (II) ARE RECENTLY ARRIVED IN THE STATE OR
RECENTLY AUTHORIZED TO PRACTICE IN THE STATE.
  4. PAYMENT FOR HEALTH CARE SERVICES. (A) THE COMMISSIONER  MAY  ESTAB-
LISH  BY  REGULATION  PAYMENT METHODOLOGIES FOR HEALTH CARE SERVICES AND
CARE COORDINATION PROVIDED TO MEMBERS UNDER THE PROGRAM BY PARTICIPATING
PROVIDERS, CARE COORDINATORS, AND HEALTH CARE ORGANIZATIONS.  THERE  MAY
BE  A VARIETY OF DIFFERENT PAYMENT METHODOLOGIES, INCLUDING THOSE ESTAB-
LISHED ON A DEMONSTRATION BASIS. ALL PAYMENT  RATES  UNDER  THE  PROGRAM
SHALL  BE  REASONABLE  AND REASONABLY RELATED TO THE COST OF EFFICIENTLY
PROVIDING THE HEALTH CARE SERVICE AND ASSURING AN ADEQUATE AND  ACCESSI-
BLE SUPPLY OF THE HEALTH CARE SERVICE.  UNTIL AND UNLESS ANOTHER PAYMENT
METHODOLOGY  IS  ESTABLISHED,  HEALTH  CARE SERVICES PROVIDED TO MEMBERS
UNDER THE PROGRAM SHALL BE PAID FOR ON A FEE-FOR-SERVICE  BASIS,  EXCEPT
FOR CARE COORDINATION.
  (B)  THE  PROGRAM  SHALL ENGAGE IN GOOD FAITH NEGOTIATIONS WITH HEALTH
CARE PROVIDERS' REPRESENTATIVES UNDER TITLE III OF ARTICLE FORTY-NINE OF
THIS CHAPTER, INCLUDING, BUT NOT LIMITED TO, IN  RELATION  TO  RATES  OF
PAYMENT AND PAYMENT METHODOLOGIES.
  (C)  NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, PAYMENT FOR
DRUGS PROVIDED BY PHARMACIES UNDER THE PROGRAM SHALL BE MADE PURSUANT TO
TITLE ONE OF ARTICLE TWO-A OF THIS CHAPTER. HOWEVER, THE  PROGRAM  SHALL
PROVIDE  FOR  PAYMENT  FOR  PRESCRIPTION DRUGS UNDER SECTION 340B OF THE
FEDERAL PUBLIC SERVICE ACT WHERE APPLICABLE.  PAYMENT  FOR  PRESCRIPTION

A. 4738--A                         11

DRUGS  PROVIDED  BY HEALTH CARE PROVIDERS OTHER THAN PHARMACIES SHALL BE
PURSUANT TO OTHER PROVISIONS OF THIS ARTICLE.
  (D)  PAYMENT  FOR  HEALTH CARE SERVICES ESTABLISHED UNDER THIS ARTICLE
SHALL BE CONSIDERED PAYMENT IN FULL. A PARTICIPATING PROVIDER SHALL  NOT
CHARGE  ANY RATE IN EXCESS OF THE PAYMENT ESTABLISHED UNDER THIS ARTICLE
FOR ANY HEALTH CARE SERVICE PROVIDED UNDER THE  PROGRAM  AND  SHALL  NOT
SOLICIT  OR  ACCEPT  PAYMENT FROM ANY MEMBER OR THIRD PARTY FOR ANY SUCH
SERVICE EXCEPT AS PROVIDED UNDER SECTION FIFTY-ONE HUNDRED NINE OF  THIS
ARTICLE.    HOWEVER,  THIS PARAGRAPH SHALL NOT PRECLUDE THE PROGRAM FROM
ACTING AS A PRIMARY OR  SECONDARY  PAYER  IN  CONJUNCTION  WITH  ANOTHER
THIRD-PARTY  PAYER  WHERE PERMITTED UNDER SECTION FIFTY-ONE HUNDRED NINE
OF THIS ARTICLE.
  (E) THE PROGRAM MAY PROVIDE IN PAYMENT METHODOLOGIES FOR  PAYMENT  FOR
CAPITAL  RELATED  EXPENSES  FOR SPECIFICALLY IDENTIFIED CAPITAL EXPENDI-
TURES INCURRED BY  NOT-FOR-PROFIT  OR  GOVERNMENTAL  ENTITIES  CERTIFIED
UNDER  ARTICLE TWENTY-EIGHT OF THIS CHAPTER. ANY CAPITAL RELATED EXPENSE
GENERATED BY A CAPITAL EXPENDITURE THAT REQUIRES  OR  REQUIRED  APPROVAL
UNDER  ARTICLE  TWENTY-EIGHT  OF  THIS  CHAPTER  MUST HAVE RECEIVED THAT
APPROVAL FOR THE CAPITAL RELATED  EXPENSE  TO  BE  PAID  FOR  UNDER  THE
PROGRAM.
  (F) PAYMENT METHODOLOGIES AND RATES SHALL INCLUDE A DISTINCT COMPONENT
OF  REIMBURSEMENT  FOR DIRECT AND INDIRECT GRADUATE MEDICAL EDUCATION AS
DEFINED, CALCULATED AND IMPLEMENTED  PURSUANT  TO  SECTION  TWENTY-EIGHT
HUNDRED SEVEN-C OF THIS CHAPTER.
  (G)  THE COMMISSIONER SHALL PROVIDE BY  REGULATION FOR PAYMENT METHOD-
OLOGIES AND PROCEDURES FOR PAYING FOR OUT-OF-STATE HEALTH CARE SERVICES.
  § 5106. HEALTH CARE ORGANIZATIONS. 1. A MEMBER MAY  CHOOSE  TO  ENROLL
WITH  AND  RECEIVE  HEALTH CARE SERVICES UNDER THE PROGRAM FROM A HEALTH
CARE ORGANIZATION.
  2. A HEALTH CARE ORGANIZATION SHALL BE  A  NOT-FOR-PROFIT  OR  GOVERN-
MENTAL ENTITY THAT IS APPROVED BY THE COMMISSIONER THAT IS:
  (A)  AN  ACCOUNTABLE  CARE ORGANIZATION UNDER ARTICLE TWENTY-NINE-E OF
THIS CHAPTER; OR
  (B) A TAFT-HARTLEY FUND (I) WITH RESPECT  TO  ITS  MEMBERS  AND  THEIR
FAMILY  MEMBERS,  AND  (II) IF ALLOWED BY APPLICABLE LAW AND APPROVED BY
THE COMMISSIONER, FOR OTHER MEMBERS OF THE PROGRAM.
  3. A HEALTH CARE ORGANIZATION MAY BE RESPONSIBLE FOR PROVIDING ALL  OR
PART OF THE HEALTH CARE SERVICES TO WHICH ITS MEMBERS ARE ENTITLED UNDER
THE  PROGRAM,  CONSISTENT  WITH THE TERMS OF ITS APPROVAL BY THE COMMIS-
SIONER.
  4. (A) THE COMMISSIONER SHALL DEVELOP  AND  IMPLEMENT  PROCEDURES  AND
STANDARDS  FOR AN ENTITY TO BE APPROVED TO BE A HEALTH CARE ORGANIZATION
IN THE PROGRAM, INCLUDING BUT NOT LIMITED TO  PROCEDURES  AND  STANDARDS
RELATING  TO  THE  REVOCATION,  SUSPENSION,  LIMITATION, OR ANNULMENT OF
APPROVAL ON A DETERMINATION THAT THE ENTITY IS NOT  COMPETENT  TO  BE  A
HEALTH  CARE  ORGANIZATION OR HAS EXHIBITED A COURSE OF CONDUCT WHICH IS
EITHER INCONSISTENT WITH PROGRAM  STANDARDS  AND  REGULATIONS  OR  WHICH
EXHIBITS  AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR IS
A POTENTIAL THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH  PROCEDURES  AND
STANDARDS  SHALL  NOT LIMIT APPROVAL TO BE A HEALTH CARE ORGANIZATION IN
THE PROGRAM FOR ECONOMIC PURPOSES AND  SHALL  BE  CONSISTENT  WITH  GOOD
PROFESSIONAL  PRACTICE.  IN DEVELOPING THE PROCEDURES AND STANDARDS, THE
COMMISSIONER  SHALL:  (I)  CONSIDER  EXISTING  STANDARDS  DEVELOPED   BY
NATIONAL  ACCREDITING  AND  PROFESSIONAL ORGANIZATIONS; AND (II) CONSULT
WITH NATIONAL AND LOCAL ORGANIZATIONS WORKING IN  THE  FIELD  OF  HEALTH
CARE  ORGANIZATIONS,  INCLUDING  HEALTH  CARE  PRACTITIONERS, HOSPITALS,

A. 4738--A                         12

CLINICS, AND CONSUMERS AND THEIR REPRESENTATIVES.  WHEN  DEVELOPING  AND
IMPLEMENTING  STANDARDS  OF  APPROVAL  OF HEALTH CARE ORGANIZATIONS, THE
COMMISSIONER SHALL CONSULT WITH THE COMMISSIONER OF MENTAL  HEALTH,  THE
COMMISSIONER  OF  DEVELOPMENTAL DISABILITIES AND THE COMMISSIONER OF THE
OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES.
  (B) TO MAINTAIN APPROVAL UNDER THE PROGRAM, A HEALTH CARE ORGANIZATION
MUST: (I) RENEW ITS STATUS AT A FREQUENCY DETERMINED BY THE  COMMISSION-
ER;  AND  (II) PROVIDE DATA TO THE DEPARTMENT AS REQUIRED BY THE COMMIS-
SIONER TO ENABLE THE COMMISSIONER TO EVALUATE THE HEALTH CARE  ORGANIZA-
TION  IN  RELATION  TO  QUALITY  OF  HEALTH  CARE  SERVICES, HEALTH CARE
OUTCOMES, AND COST.
  5. THE COMMISSIONER SHALL MAKE REGULATIONS  RELATING  TO  HEALTH  CARE
ORGANIZATIONS  CONSISTENT  WITH AND TO ENSURE COMPLIANCE WITH THIS ARTI-
CLE.
  6. THE PROVISION OF HEALTH CARE SERVICES DIRECTLY OR INDIRECTLY  BY  A
HEALTH  CARE  ORGANIZATION  THROUGH  HEALTH  CARE PROVIDERS SHALL NOT BE
CONSIDERED THE PRACTICE OF A PROFESSION UNDER TITLE EIGHT OF THE  EDUCA-
TION LAW BY THE HEALTH CARE ORGANIZATION.
  §  5107.  PROGRAM  STANDARDS.  1.  THE  COMMISSIONER  SHALL  ESTABLISH
REQUIREMENTS AND STANDARDS FOR THE PROGRAM AND FOR HEALTH CARE ORGANIZA-
TIONS, CARE COORDINATORS, AND HEALTH  CARE  PROVIDERS,  CONSISTENT  WITH
THIS ARTICLE, INCLUDING REQUIREMENTS AND STANDARDS FOR, AS APPLICABLE:
  (A) THE SCOPE, QUALITY AND ACCESSIBILITY OF HEALTH CARE SERVICES;
  (B) RELATIONS BETWEEN HEALTH CARE ORGANIZATIONS OR HEALTH CARE PROVID-
ERS AND MEMBERS; AND
  (C)  RELATIONS  BETWEEN  HEALTH  CARE  ORGANIZATIONS  AND  HEALTH CARE
PROVIDERS, INCLUDING (I) CREDENTIALING AND PARTICIPATION IN  THE  HEALTH
CARE ORGANIZATION; AND (II) TERMS, METHODS AND RATES OF PAYMENT.
  2. REQUIREMENTS AND STANDARDS UNDER THE PROGRAM SHALL INCLUDE, BUT NOT
BE LIMITED TO, PROVISIONS TO PROMOTE THE FOLLOWING:
  (A)  SIMPLIFICATION,  TRANSPARENCY, UNIFORMITY, AND FAIRNESS IN HEALTH
CARE PROVIDER CREDENTIALING AND PARTICIPATION IN HEALTH  CARE  ORGANIZA-
TION  NETWORKS, REFERRALS, PAYMENT PROCEDURES AND RATES, CLAIMS PROCESS-
ING, AND APPROVAL OF HEALTH CARE SERVICES, AS APPLICABLE;
  (B) PRIMARY AND PREVENTIVE  CARE,  CARE  COORDINATION,  EFFICIENT  AND
EFFECTIVE  HEALTH  CARE  SERVICES,  QUALITY  ASSURANCE, COORDINATION AND
INTEGRATION OF HEALTH CARE SERVICES, INCLUDING USE OF APPROPRIATE  TECH-
NOLOGY, AND PROMOTION OF PUBLIC, ENVIRONMENTAL AND OCCUPATIONAL HEALTH;
  (C) ELIMINATION OF HEALTH CARE DISPARITIES;
  (D) NON-DISCRIMINATION WITH RESPECT TO MEMBERS AND HEALTH CARE PROVID-
ERS ON THE BASIS OF RACE, ETHNICITY, NATIONAL ORIGIN, RELIGION, DISABIL-
ITY,  AGE,  SEX,  SEXUAL  ORIENTATION, GENDER IDENTITY OR EXPRESSION, OR
ECONOMIC CIRCUMSTANCES; PROVIDED  THAT  HEALTH  CARE  SERVICES  PROVIDED
UNDER THE PROGRAM SHALL BE APPROPRIATE TO THE PATIENT'S CLINICALLY-RELE-
VANT CIRCUMSTANCES; AND
  (E)  ACCESSIBILITY  OF  CARE  COORDINATION,  HEALTH  CARE ORGANIZATION
SERVICES AND HEALTH CARE SERVICES, INCLUDING  ACCESSIBILITY  FOR  PEOPLE
WITH DISABILITIES AND PEOPLE WITH LIMITED ABILITY TO SPEAK OR UNDERSTAND
ENGLISH,  AND  THE PROVIDING OF CARE COORDINATION, HEALTH CARE ORGANIZA-
TION SERVICES AND HEALTH CARE SERVICES IN A CULTURALLY COMPETENT MANNER.
  3. ANY PARTICIPATING PROVIDER OR CARE COORDINATOR THAT IS ORGANIZED AS
A FOR-PROFIT ENTITY (OTHER THAN A PROFESSIONAL PRACTICE OF ONE  OR  MORE
HEALTH  CARE  PROFESSIONALS) SHALL BE REQUIRED TO MEET THE SAME REQUIRE-
MENTS AND STANDARDS AS ENTITIES ORGANIZED  AS  NOT-FOR-PROFIT  ENTITIES,
AND PAYMENTS UNDER THE PROGRAM PAID TO SUCH ENTITIES SHALL NOT BE CALCU-
LATED  TO  ACCOMMODATE THE GENERATION OF PROFIT OR REVENUE FOR DIVIDENDS

A. 4738--A                         13

OR OTHER RETURN ON INVESTMENT OR THE PAYMENT OF TAXES THAT WOULD NOT  BE
PAID BY A NOT-FOR-PROFIT ENTITY.
  4.  EVERY  PARTICIPATING  PROVIDER  SHALL  FURNISH TO THE PROGRAM SUCH
INFORMATION TO, AND PERMIT EXAMINATION OF ITS RECORDS BY,  THE  PROGRAM,
AS  MAY  BE  REASONABLY REQUIRED FOR PURPOSES OF REVIEWING ACCESSIBILITY
AND UTILIZATION OF HEALTH CARE SERVICES,  QUALITY  ASSURANCE,  PROMOTING
IMPROVED  PATIENT OUTCOMES AND COST CONTAINMENT, THE MAKING OF PAYMENTS,
AND STATISTICAL OR OTHER STUDIES OF THE OPERATION OF THE PROGRAM OR  FOR
PROTECTION  AND  PROMOTION  OF  PUBLIC,  ENVIRONMENTAL  AND OCCUPATIONAL
HEALTH.
  5. IN DEVELOPING REQUIREMENTS AND STANDARDS AND  MAKING  OTHER  POLICY
DETERMINATIONS  UNDER  THIS ARTICLE, THE COMMISSIONER SHALL CONSULT WITH
REPRESENTATIVES OF MEMBERS, HEALTH CARE  PROVIDERS,  CARE  COORDINATORS,
HEALTH  CARE ORGANIZATIONS  EMPLOYERS, ORGANIZED LABOR, AND OTHER INTER-
ESTED PARTIES.
  6. THE PROGRAM SHALL MAINTAIN THE SECURITY AND CONFIDENTIALITY OF  ALL
DATA  AND  OTHER  INFORMATION COLLECTED UNDER THE PROGRAM WHEN SUCH DATA
WOULD BE NORMALLY CONSIDERED CONFIDENTIAL PATIENT DATA.  AGGREGATE  DATA
OF  THE  PROGRAM  WHICH  IS  DERIVED FROM CONFIDENTIAL DATA BUT DOES NOT
VIOLATE PATIENT CONFIDENTIALITY SHALL BE  PUBLIC  INFORMATION  INCLUDING
FOR PURPOSES OF ARTICLE SIX OF THE PUBLIC OFFICERS LAW.
  §  5108. REGULATIONS. THE COMMISSIONER MAY MAKE REGULATIONS UNDER THIS
ARTICLE BY APPROVING REGULATIONS AND AMENDMENTS THERETO, UNDER  SUBDIVI-
SION  ONE  OF SECTION FIFTY-ONE HUNDRED TWO OF THIS ARTICLE. THE COMMIS-
SIONER MAY MAKE REGULATIONS OR AMENDMENTS THERETO UNDER THIS ARTICLE  ON
AN  EMERGENCY  BASIS UNDER SECTION TWO HUNDRED TWO OF THE STATE ADMINIS-
TRATIVE PROCEDURE ACT, PROVIDED  THAT  SUCH  REGULATIONS  OR  AMENDMENTS
SHALL  NOT  BECOME  PERMANENT  UNLESS  ADOPTED  UNDER SUBDIVISION ONE OF
SECTION FIFTY-ONE HUNDRED TWO OF THIS ARTICLE.
  § 5109. PROVISIONS RELATING TO FEDERAL HEALTH PROGRAMS. 1. THE COMMIS-
SIONER SHALL SEEK ALL FEDERAL WAIVERS AND OTHER  FEDERAL  APPROVALS  AND
ARRANGEMENTS  AND  SUBMIT STATE PLAN AMENDMENTS NECESSARY TO OPERATE THE
PROGRAM CONSISTENT WITH THIS ARTICLE TO THE MAXIMUM EXTENT POSSIBLE.
  2. (A) THE COMMISSIONER SHALL APPLY TO THE  SECRETARY  OF  HEALTH  AND
HUMAN  SERVICES OR OTHER APPROPRIATE FEDERAL OFFICIAL FOR ALL WAIVERS OF
REQUIREMENTS, AND MAKE OTHER ARRANGEMENTS, UNDER MEDICARE, ANY  FEDERAL-
LY-MATCHED PUBLIC HEALTH PROGRAM, THE AFFORDABLE CARE ACT, AND ANY OTHER
FEDERAL  PROGRAMS THAT PROVIDE FEDERAL FUNDS FOR PAYMENT FOR HEALTH CARE
SERVICES, THAT ARE NECESSARY TO ENABLE ALL NEW YORK  HEALTH  MEMBERS  TO
RECEIVE ALL BENEFITS UNDER THE PROGRAM THROUGH THE PROGRAM TO ENABLE THE
STATE  TO  IMPLEMENT THIS ARTICLE AND TO RECEIVE AND DEPOSIT ALL FEDERAL
PAYMENTS UNDER THOSE PROGRAMS (INCLUDING FUNDS THAT MAY BE  PROVIDED  IN
LIEU  OF PREMIUM TAX CREDITS, COST-SHARING SUBSIDIES, AND SMALL BUSINESS
TAX CREDITS) IN THE STATE TREASURY TO THE CREDIT OF THE NEW YORK  HEALTH
TRUST  FUND  AND  TO USE THOSE FUNDS FOR THE NEW YORK HEALTH PROGRAM AND
OTHER PROVISIONS UNDER THIS ARTICLE. TO THE EXTENT POSSIBLE, THE COMMIS-
SIONER SHALL NEGOTIATE ARRANGEMENTS WITH THE FEDERAL GOVERNMENT IN WHICH
BULK OR LUMP-SUM FEDERAL PAYMENTS ARE PAID TO NEW YORK HEALTH  IN  PLACE
OF  FEDERAL  SPENDING  OR  TAX  BENEFITS  FOR  FEDERALLY-MATCHED  HEALTH
PROGRAMS OR FEDERAL HEALTH PROGRAMS.
  (B) THE COMMISSIONER MAY REQUIRE MEMBERS OR APPLICANTS TO  BE  MEMBERS
TO  PROVIDE  INFORMATION  NECESSARY  FOR  THE PROGRAM TO COMPLY WITH ANY
WAIVER OR ARRANGEMENT UNDER THIS SUBDIVISION.
  3. (A) THE COMMISSIONER MAY TAKE ACTIONS CONSISTENT WITH THIS  ARTICLE
TO  ENABLE  NEW YORK HEALTH TO ADMINISTER MEDICARE IN NEW YORK STATE, TO
CREATE A MEDICARE MANAGED CARE PLAN ("MEDICARE  ADVANTAGE")  THAT  WOULD

A. 4738--A                         14

OPERATE  CONSISTENT  WITH  THIS  ARTICLE,  AND  TO BE A PROVIDER OF DRUG
COVERAGE UNDER MEDICARE PART D FOR ELIGIBLE MEMBERS OF NEW YORK HEALTH.
  (B)  THE  COMMISSIONER  MAY  WAIVE  OR  MODIFY  THE  APPLICABILITY  OF
PROVISIONS OF THIS SECTION  RELATING  TO  ANY  FEDERALLY-MATCHED  PUBLIC
HEALTH  PROGRAM  OR  MEDICARE  AS  NECESSARY  TO IMPLEMENT ANY WAIVER OR
ARRANGEMENT UNDER THIS SECTION OR TO MAXIMIZE THE  BENEFIT  TO  THE  NEW
YORK  HEALTH PROGRAM UNDER THIS SECTION, PROVIDED THAT THE COMMISSIONER,
IN CONSULTATION WITH THE DIRECTOR OF THE BUDGET,  SHALL  DETERMINE  THAT
SUCH  WAIVER  OR  MODIFICATION  IS  IN THE BEST INTERESTS OF THE MEMBERS
AFFECTED BY THE ACTION AND THE STATE.
  (C) THE COMMISSIONER MAY  APPLY  FOR  COVERAGE  UNDER  ANY  FEDERALLY-
MATCHED  PUBLIC  HEALTH  PROGRAM  ON BEHALF OF ANY MEMBER AND ENROLL THE
MEMBER IN THE FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM OR MEDICARE IF THE
MEMBER IS ELIGIBLE FOR IT.   ENROLLMENT IN  A  FEDERALLY-MATCHED  PUBLIC
HEALTH PROGRAM OR MEDICARE SHALL NOT CAUSE ANY MEMBER TO LOSE ANY HEALTH
CARE  SERVICE  PROVIDED  BY THE PROGRAM OR DIMINISH ANY RIGHT THE MEMBER
WOULD OTHERWISE HAVE.
  (D) THE COMMISSIONER SHALL BY REGULATION INCREASE THE INCOME ELIGIBIL-
ITY LEVEL, INCREASE OR ELIMINATE  THE  RESOURCE  TEST  FOR  ELIGIBILITY,
SIMPLIFY ANY PROCEDURAL OR DOCUMENTATION REQUIREMENT FOR ENROLLMENT, AND
INCREASE  THE  BENEFITS FOR ANY FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM,
AND FOR ANY PROGRAM TO REDUCE OR ELIMINATE AN INDIVIDUAL'S  COINSURANCE,
COST-SHARING  OR  PREMIUM OBLIGATIONS OR INCREASE AN INDIVIDUAL'S ELIGI-
BILITY FOR ANY FEDERAL FINANCIAL SUPPORT  RELATED  TO  MEDICARE  OR  THE
AFFORDABLE CARE ACT NOTWITHSTANDING ANY LAW OR REGULATION TO THE CONTRA-
RY.  THE  COMMISSIONER  MAY  ACT  UNDER  THIS  PARAGRAPH UPON A FINDING,
APPROVED BY THE DIRECTOR OF THE BUDGET, THAT THE ACTION (I) WILL HELP TO
INCREASE THE NUMBER OF MEMBERS WHO ARE  ELIGIBLE  FOR  AND  ENROLLED  IN
FEDERALLY-MATCHED  PUBLIC  HEALTH PROGRAMS, OR FOR ANY PROGRAM TO REDUCE
OR ELIMINATE AN INDIVIDUAL'S COINSURANCE, COST-SHARING OR PREMIUM  OBLI-
GATIONS  OR  INCREASE AN INDIVIDUAL'S ELIGIBILITY FOR ANY FEDERAL FINAN-
CIAL SUPPORT RELATED TO MEDICARE OR THE AFFORDABLE CARE ACT;  (II)  WILL
NOT DIMINISH ANY INDIVIDUAL'S ACCESS TO ANY HEALTH CARE SERVICE, BENEFIT
OR  RIGHT  THE INDIVIDUAL WOULD OTHERWISE HAVE; (III) IS IN THE INTEREST
OF THE PROGRAM; AND (IV) DOES NOT REQUIRE OR HAS RECEIVED ANY  NECESSARY
FEDERAL  WAIVERS OR APPROVALS TO ENSURE FEDERAL FINANCIAL PARTICIPATION.
ACTIONS UNDER THIS PARAGRAPH SHALL NOT APPLY TO ELIGIBILITY FOR  PAYMENT
FOR LONG TERM CARE.
  (E)  TO ENABLE THE COMMISSIONER TO APPLY FOR COVERAGE UNDER ANY FEDER-
ALLY-MATCHED PUBLIC HEALTH PROGRAM OR MEDICARE ON BEHALF OF  ANY  MEMBER
AND  ENROLL THE MEMBER IN THE FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM OR
MEDICARE IF THE MEMBER IS ELIGIBLE FOR IT, THE COMMISSIONER MAY  REQUIRE
THAT  EVERY MEMBER OR APPLICANT TO BE A MEMBER SHALL PROVIDE INFORMATION
TO ENABLE THE COMMISSIONER TO DETERMINE WHETHER THE APPLICANT IS  ELIGI-
BLE  FOR A FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM AND FOR MEDICARE (AND
ANY PROGRAM OR BENEFIT UNDER MEDICARE). THE PROGRAM SHALL MAKE A REASON-
ABLE EFFORT TO NOTIFY MEMBERS OF THEIR OBLIGATIONS UNDER THIS PARAGRAPH.
AFTER A REASONABLE EFFORT HAS BEEN  MADE  TO  CONTACT  THE  MEMBER,  THE
MEMBER  SHALL  BE  NOTIFIED  IN WRITING THAT HE OR SHE HAS SIXTY DAYS TO
PROVIDE SUCH REQUIRED INFORMATION. IF SUCH INFORMATION IS  NOT  PROVIDED
WITHIN THE SIXTY DAY PERIOD, THE MEMBER'S COVERAGE UNDER THE PROGRAM MAY
BE TERMINATED.
  (F)  TO THE EXTENT NECESSARY FOR PURPOSES OF THIS SECTION, AS A CONDI-
TION OF  CONTINUED  ELIGIBILITY  FOR  HEALTH  CARE  SERVICES  UNDER  THE
PROGRAM,  A  MEMBER  WHO  IS  ELIGIBLE FOR BENEFITS UNDER MEDICARE SHALL
ENROLL IN MEDICARE, INCLUDING PARTS A, B AND D.

A. 4738--A                         15

  (G) THE PROGRAM SHALL  PROVIDE  PREMIUM  ASSISTANCE  FOR  ALL  MEMBERS
ENROLLING  IN  A  MEDICARE  PART  D DRUG COVERAGE UNDER SECTION 1860D OF
TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT LIMITED TO THE LOW-INCOME
BENCHMARK PREMIUM AMOUNT ESTABLISHED BY THE FEDERAL CENTERS FOR MEDICARE
AND MEDICAID SERVICES AND ANY OTHER AMOUNT WHICH SUCH AGENCY ESTABLISHES
UNDER  ITS  DE MINIMIS PREMIUM POLICY, EXCEPT THAT SUCH PAYMENTS MADE ON
BEHALF OF MEMBERS ENROLLED IN A MEDICARE ADVANTAGE PLAN MAY  EXCEED  THE
LOW-INCOME  BENCHMARK  PREMIUM AMOUNT IF DETERMINED TO BE COST EFFECTIVE
TO THE PROGRAM.
  (H) IF THE COMMISSIONER HAS  REASONABLE  GROUNDS  TO  BELIEVE  THAT  A
MEMBER  COULD  BE  ELIGIBLE  FOR AN INCOME-RELATED SUBSIDY UNDER SECTION
1860D-14 OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT,  THE  MEMBER
SHALL  PROVIDE,  AND AUTHORIZE THE PROGRAM TO OBTAIN, ANY INFORMATION OR
DOCUMENTATION REQUIRED TO ESTABLISH THE MEMBER'S  ELIGIBILITY  FOR  SUCH
SUBSIDY,  PROVIDED THAT THE COMMISSIONER SHALL ATTEMPT TO OBTAIN AS MUCH
OF THE INFORMATION AND DOCUMENTATION AS POSSIBLE FROM RECORDS  THAT  ARE
AVAILABLE TO HIM OR HER.
  (I)  THE  PROGRAM  SHALL MAKE A REASONABLE EFFORT TO NOTIFY MEMBERS OF
THEIR OBLIGATIONS UNDER THIS SUBDIVISION. AFTER A REASONABLE EFFORT  HAS
BEEN MADE TO CONTACT THE MEMBER, THE MEMBER SHALL BE NOTIFIED IN WRITING
THAT  HE  OR SHE HAS SIXTY DAYS TO PROVIDE SUCH REQUIRED INFORMATION. IF
SUCH INFORMATION IS NOT  PROVIDED  WITHIN  THE  SIXTY  DAY  PERIOD,  THE
MEMBER'S COVERAGE UNDER THE PROGRAM MAY BE TERMINATED.
  §  5110.  ADDITIONAL  PROVISIONS.   1. THE COMMISSIONER SHALL CONTRACT
WITH NOT-FOR-PROFIT ORGANIZATIONS TO PROVIDE:
  (A) CONSUMER ASSISTANCE TO INDIVIDUALS WITH RESPECT TO  SELECTION  AND
CHANGING  SELECTION  OF  A CARE COORDINATOR OR HEALTH CARE ORGANIZATION,
ENROLLING, OBTAINING HEALTH CARE SERVICES, AND OTHER MATTERS RELATING TO
THE PROGRAM;
  (B) HEALTH CARE PROVIDER ASSISTANCE TO HEALTH CARE PROVIDERS PROVIDING
AND SEEKING OR CONSIDERING WHETHER  TO  PROVIDE,  HEALTH  CARE  SERVICES
UNDER THE PROGRAM, WITH RESPECT TO PARTICIPATING IN A HEALTH CARE ORGAN-
IZATION AND DEALING WITH A HEALTH CARE ORGANIZATION; AND
  (C)  CARE COORDINATOR ASSISTANCE TO INDIVIDUALS AND ENTITIES PROVIDING
AND SEEKING OR CONSIDERING WHETHER  TO  PROVIDE,  CARE  COORDINATION  TO
MEMBERS.
  2.  THE  COMMISSIONER  SHALL PROVIDE GRANTS FROM FUNDS IN THE NEW YORK
HEALTH TRUST FUND OR OTHERWISE APPROPRIATED FOR THIS PURPOSE, TO  HEALTH
SYSTEMS  AGENCIES UNDER SECTION TWENTY-NINE HUNDRED FOUR-B OF THIS CHAP-
TER TO SUPPORT THE OPERATION OF SUCH HEALTH SYSTEMS AGENCIES.
  3. THE COMMISSIONER SHALL PROVIDE FUNDS FROM THE NEW YORK HEALTH TRUST
FUND OR OTHERWISE APPROPRIATED FOR THIS PURPOSE TO THE  COMMISSIONER  OF
LABOR  FOR  A  PROGRAM  FOR  RETRAINING AND ASSISTING JOB TRANSITION FOR
INDIVIDUALS EMPLOYED OR PREVIOUSLY  EMPLOYED  IN  THE  FIELD  OF  HEALTH
INSURANCE  AND  OTHER  THIRD-PARTY  PAYMENT FOR HEALTH CARE OR PROVIDING
SERVICES TO HEALTH CARE PROVIDERS TO DEAL WITH  THIRD-PARTY  PAYERS  FOR
HEALTH  CARE,  WHOSE  JOBS  MAY BE OR HAVE BEEN ENDED AS A RESULT OF THE
IMPLEMENTATION OF THE NEW YORK HEALTH PROGRAM, CONSISTENT WITH OTHERWISE
APPLICABLE LAW.
  4. THE COMMISSIONER SHALL, DIRECTLY AND THROUGH GRANTS TO NOT-FOR-PRO-
FIT ENTITIES, CONDUCT PROGRAMS USING DATA COLLECTED THROUGH THE NEW YORK
HEALTH PROGRAM, TO PROMOTE  AND  PROTECT  THE  QUALITY  OF  HEALTH  CARE
SERVICES,  PATIENT  OUTCOMES, AND PUBLIC, ENVIRONMENTAL AND OCCUPATIONAL
HEALTH, INCLUDING COOPERATION WITH OTHER DATA  COLLECTION  AND  RESEARCH
PROGRAMS OF THE DEPARTMENT, CONSISTENT WITH THIS ARTICLE, THE PROTECTION

A. 4738--A                         16

OF THE SECURITY AND CONFIDENTIALITY OF INDIVIDUALLY IDENTIFIABLE PATIENT
INFORMATION, AND OTHERWISE APPLICABLE LAW.
  §  5111.  REGIONAL ADVISORY COUNCILS.  1. THE NEW YORK HEALTH REGIONAL
ADVISORY COUNCILS (EACH REFERRED TO IN THIS ARTICLE AS A "REGIONAL ADVI-
SORY COUNCIL") ARE HEREBY CREATED IN THE DEPARTMENT.
  2. THERE SHALL BE A REGIONAL ADVISORY COUNCIL ESTABLISHED IN  EACH  OF
THE FOLLOWING REGIONS:
  (A) LONG ISLAND, CONSISTING OF NASSAU AND SUFFOLK COUNTIES;
  (B) NEW YORK CITY;
  (C)  HUDSON  VALLEY, CONSISTING OF DELAWARE, DUTCHESS, ORANGE, PUTNAM,
ROCKLAND, SULLIVAN, ULSTER, WESTCHESTER COUNTIES;
  (D) NORTHERN, CONSISTING OF ALBANY, CLINTON, COLUMBIA,  ESSEX,  FRANK-
LIN, FULTON, GREENE, HAMILTON, MONTGOMERY, OTSEGO, RENSSELAER, SARATOGA,
SCHENECTADY, SCHOHARIE, WARREN, WASHINGTON COUNTIES;
  (E)  CENTRAL,  CONSISTING  OF BROOME, CAYUGA, CHEMUNG, CHENANGO, CORT-
LAND, HERKIMER, JEFFERSON, LEWIS, LIVINGSTON, MADISON,  MONROE,  ONEIDA,
ONONDAGA,  ONTARIO,  OSWEGO,  SCHUYLER,  SENECA,  ST. LAWRENCE, STEUBEN,
TIOGA, TOMPKINS, WAYNE, YATES COUNTIES; AND
  (F) WESTERN, CONSISTING OF ALLEGANY,  CATTARAUGUS,  CHAUTAUQUA,  ERIE,
GENESEE, NIAGARA, ORLEANS, WYOMING COUNTIES.
  3.  EACH REGIONAL ADVISORY COUNCIL SHALL BE COMPOSED OF NOT FEWER THAN
TWENTY-SEVEN MEMBERS, AS DETERMINED BY THE COMMISSIONER AND  THE  BOARD,
AS  NECESSARY  TO APPROPRIATELY REPRESENT THE DIVERSE NEEDS AND CONCERNS
OF THE REGION. MEMBERS OF A REGIONAL ADVISORY COUNCIL SHALL BE RESIDENTS
OF OR HAVE THEIR PRINCIPAL PLACE OF BUSINESS IN THE REGION SERVED BY THE
REGIONAL ADVISORY COUNCIL.
  4. APPOINTMENT OF MEMBERS OF THE REGIONAL ADVISORY COUNCILS.
  (A) THE TWENTY-SEVEN MEMBERS SHALL BE APPOINTED AS FOLLOWS:
  (I) NINE MEMBERS SHALL BE APPOINTED BY THE GOVERNOR;
  (II) SIX MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE RECOMMENDA-
TION OF THE SPEAKER OF THE ASSEMBLY;
  (III) SIX MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE  RECOMMEN-
DATION OF THE TEMPORARY PRESIDENT OF THE SENATE;
  (IV) THREE MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE RECOMMEN-
DATION OF THE MINORITY LEADER OF THE ASSEMBLY; AND
  (V)  THREE MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE RECOMMEN-
DATION OF THE MINORITY LEADER OF THE SENATE.
  WHERE A REGIONAL ADVISORY COUNCIL HAS MORE THAN TWENTY-SEVEN  MEMBERS,
ADDITIONAL MEMBERS SHALL BE APPOINTED AND RECOMMENDED BY THESE OFFICIALS
IN THE SAME PROPORTION AS THE TWENTY-SEVEN MEMBERS.
  (B)  REGIONAL  ADVISORY  COUNCIL  MEMBERSHIP  SHALL INCLUDE BUT NOT BE
LIMITED TO:
  (I) REPRESENTATIVES OF HEALTH  CARE  CONSUMER  ADVOCACY  ORGANIZATIONS
WITH  A REGIONAL CONSTITUENCY, WHO SHALL REPRESENT AT LEAST ONE THIRD OF
THE MEMBERSHIP OF EACH REGIONAL COUNCIL;
  (II) REPRESENTATIVES OF PROFESSIONAL ORGANIZATIONS REPRESENTING PHYSI-
CIANS;
  (III)  REPRESENTATIVES  OF  PROFESSIONAL  ORGANIZATIONS   REPRESENTING
HEALTH CARE PROFESSIONALS OTHER THAN PHYSICIANS;
  (IV) REPRESENTATIVES OF GENERAL HOSPITALS, INCLUDING PUBLIC HOSPITALS;
  (V) REPRESENTATIVES OF COMMUNITY HEALTH CENTERS;
  (VI)  REPRESENTATIVES  OF  MENTAL HEALTH, BEHAVIORAL HEALTH (INCLUDING
SUBSTANCE USE), PHYSICAL DISABILITY, DEVELOPMENTAL DISABILITY, REHABILI-
TATION, HOME CARE AND OTHER SERVICE PROVIDERS;
  (VII) REPRESENTATIVES OF WOMEN'S HEALTH SERVICE PROVIDERS;
  (VIII) REPRESENTATIVES OF HEALTH CARE ORGANIZATIONS;

A. 4738--A                         17

  (IX) REPRESENTATIVES OF ORGANIZED LABOR;
  (X) REPRESENTATIVES OF EMPLOYERS; AND
  (XI) REPRESENTATIVES OF MUNICIPAL AND COUNTY GOVERNMENT.
  5. MEMBERS OF A REGIONAL ADVISORY COUNCIL SHALL BE APPOINTED FOR TERMS
OF  THREE  YEARS PROVIDED, HOWEVER, THAT OF THE MEMBERS FIRST APPOINTED,
ONE-THIRD SHALL BE APPOINTED FOR ONE YEAR TERMS AND ONE-THIRD  SHALL  BE
APPOINTED  FOR  TWO  YEAR  TERMS.  VACANCIES SHALL BE FILLED IN THE SAME
MANNER AS ORIGINAL APPOINTMENTS FOR THE REMAINDER OF ANY UNEXPIRED TERM.
NO PERSON SHALL BE A MEMBER OF A REGIONAL ADVISORY COUNCIL FOR MORE THAN
SIX YEARS IN ANY PERIOD OF TWELVE CONSECUTIVE YEARS.
  6. MEMBERS OF THE  REGIONAL  ADVISORY  COUNCILS  SHALL  SERVE  WITHOUT
COMPENSATION  BUT  SHALL  BE  REIMBURSED  FOR THEIR NECESSARY AND ACTUAL
EXPENSES INCURRED WHILE ENGAGED IN THE BUSINESS OF  THE  ADVISORY  COUN-
CILS.  THE PROGRAM SHALL PROVIDE FINANCIAL SUPPORT FOR SUCH EXPENSES AND
OTHER EXPENSES OF THE REGIONAL ADVISORY COUNCILS.
  7. EACH REGIONAL ADVISORY COUNCIL SHALL MEET AT LEAST QUARTERLY.  EACH
REGIONAL  ADVISORY COUNCIL MAY FORM COMMITTEES TO ASSIST IT IN ITS WORK.
MEMBERS OF A COMMITTEE NEED NOT BE  MEMBERS  OF  THE  REGIONAL  ADVISORY
COUNCIL.    THE  NEW  YORK  CITY  REGIONAL ADVISORY COUNCIL SHALL FORM A
COMMITTEE FOR EACH BOROUGH OF NEW YORK  CITY,  TO  ASSIST  THE  REGIONAL
ADVISORY COUNCIL IN ITS WORK AS IT RELATES PARTICULARLY TO THAT BOROUGH.
  8.  EACH  REGIONAL  ADVISORY COUNCIL SHALL ADVISE THE COMMISSIONER,THE
BOARD, THE GOVERNOR AND THE LEGISLATURE ON ALL MATTERS RELATING  TO  THE
DEVELOPMENT AND IMPLEMENTATION OF THE NEW YORK HEALTH PROGRAM.
  9.  EACH  REGIONAL ADVISORY COUNCIL SHALL ADOPT, AND FROM TIME TO TIME
REVISE, A COMMUNITY HEALTH IMPROVEMENT  PLAN  FOR  ITS  REGION  FOR  THE
PURPOSE OF:
  (A)  PROMOTING  THE  DELIVERY  OF  HEALTH CARE SERVICES IN THE REGION,
IMPROVING THE QUALITY AND  ACCESSIBILITY  OF  CARE,  INCLUDING  CULTURAL
COMPETENCY,  CLINICAL  INTEGRATION  OF  CARE  BETWEEN  SERVICE PROVIDERS
INCLUDING BUT NOT LIMITED TO PHYSICAL, MENTAL,  AND  BEHAVIORAL  HEALTH,
PHYSICAL AND DEVELOPMENTAL DISABILITY SERVICES, AND LONG-TERM CARE;
  (B) FACILITY AND HEALTH SERVICES PLANNING IN THE REGION;
  (C) IDENTIFYING GAPS IN REGIONAL HEALTH CARE SERVICES; AND
  (D)  PROMOTING INCREASED PUBLIC KNOWLEDGE AND RESPONSIBILITY REGARDING
THE AVAILABILITY AND APPROPRIATE UTILIZATION OF  HEALTH  CARE  SERVICES.
EACH COMMUNITY HEALTH IMPROVEMENT PLAN SHALL BE SUBMITTED TO THE COMMIS-
SIONER AND THE BOARD AND SHALL BE POSTED ON THE DEPARTMENT'S WEBSITE.
  10.  EACH  REGIONAL  ADVISORY  COUNCIL SHALL HOLD AT LEAST FOUR PUBLIC
HEARINGS ANNUALLY ON MATTERS RELATING TO THE NEW YORK HEALTH PROGRAM AND
THE DEVELOPMENT AND IMPLEMENTATION OF THE COMMUNITY  HEALTH  IMPROVEMENT
PLAN.
  11.  EACH  REGIONAL ADVISORY COUNCIL SHALL PUBLISH AN ANNUAL REPORT TO
THE COMMISSIONER AND THE BOARD ON THE PROGRESS OF THE  COMMUNITY  HEALTH
IMPROVEMENT  PLAN.  THESE  REPORTS  SHALL  BE POSTED ON THE DEPARTMENT'S
WEBSITE.
  12. ALL MEETINGS OF THE  REGIONAL  ADVISORY  COUNCILS  AND  COMMITTEES
SHALL BE SUBJECT TO ARTICLE SIX OF THE PUBLIC OFFICERS LAW.
  § 4. Financing of New York Health. 1. The governor shall submit to the
legislature  a  revenue plan and legislative bills to implement the plan
(referred to collectively in this section as the "revenue proposal")  to
provide the revenue necessary to finance the New York Health program, as
created  by  article  51  of the public health law and all provisions of
that article (referred to in this section as the "program"), taking into
consideration anticipated federal revenue available for the program. The
revenue proposal shall be submitted to the legislature as  part  of  the

A. 4738--A                         18

executive  budget  under  article VII of the state constitution, for the
fiscal year commencing on the first day of April in  the  calendar  year
after  this  act shall become a law. In developing the revenue proposal,
the  governor  shall consult with appropriate officials of the executive
branch; the temporary president of the senate; the speaker of the assem-
bly; the chairs of the fiscal and health committees of  the  senate  and
assembly;  and  representatives  of business, labor, consumers and local
government.
  2. (a) Basic structure. The basic structure of  the  revenue  proposal
shall  be  as follows: Revenue for the program shall come from two taxes
(referred to collectively in this section as the "taxes"). First,  there
shall  be a progressively graduated tax on all payroll and self-employed
income (referred to in this section  as  the  "payroll  tax"),  paid  by
employers, employees and self-employed individuals.  Second, there shall
be  a  progressively  graduated tax on taxable income (such as interest,
dividends, and capital gains) not subject to the payroll  tax  (referred
to in this section as the "non-payroll tax").  Higher brackets of income
subject  to  the  taxes shall be assessed at a higher marginal rate than
lower brackets.  The taxes shall be set at levels anticipated to produce
sufficient revenue to finance the program, to be scaled up as enrollment
grows, taking into consideration anticipated federal  revenue  available
for  the  program.  Provision shall be made for state residents (who are
eligible for the program) who are employed out-of-state,  and  non-resi-
dents  (who  are  not  eligible for the program) who are employed in the
state.
  (b) Payroll tax. The income to be subject to the payroll tax shall  be
all income subject to the Medicare Part A tax. The tax shall be set at a
percentage  of  that  income, which shall be progressively graduated, so
the percentage is higher on higher  brackets  of  income.  For  employed
individuals,  the  employer  shall pay eighty percent of the tax and the
employee shall pay twenty percent of the tax, except  that  an  employer
may  agree  to pay all or part of the employee's share.  A self-employed
individual shall pay the full tax.
  (c) Non-payroll income tax. There shall be a tax  on  income  that  is
subject  to  the personal income tax under article 22 of the tax law and
is not subject to the payroll tax. It shall be set at  a  percentage  of
that  income,  which shall be progressively graduated, so the percentage
is higher on higher brackets of income.
  (d) Phased-in rates. Early in the program, when enrollment is growing,
the amount of the taxes shall be at an appropriate level, and  shall  be
changed as anticipated enrollment grows, to cover the actual cost of the
program.  The revenue proposal shall include a mechanism for determining
the rates of the taxes.
  (e) Cross-border employees. (i) State residents employed out-of-state.
If an individual is employed out-of-state by an employer that is subject
to New York state law, the employer and employee shall  be  required  to
pay the payroll tax as to that employee as if the employment were in the
state.  If an individual is employed out-of-state by an employer that is
not subject to New York state law, either (A) the employer and  employee
shall  voluntarily comply with the tax or (B) the employee shall pay the
tax as if he or she were self-employed.
  (ii) Out-of-state residents employed in the state.   (A)  The  payroll
tax shall apply to any out-of-state resident who is employed or self-em-
ployed in the state.  (B) In the case of an out-of-state resident who is
employed or self-employed in the state, such individual and individual's
employer  shall  be able to take a credit against the payroll taxes each

A. 4738--A                         19

would otherwise pay as to that individual for amounts they spend respec-
tively on health benefits for the individual  that  would  otherwise  be
covered  by  the program if the individual were a member of the program.
For  the  employer, the credit shall be available regardless of the form
of the health benefit (e.g.,  health  insurance,  a  self-insured  plan,
direct  services,  or reimbursement for services), to make sure that the
revenue proposal does not relate to employment benefits in violation  of
the federal ERISA.  For non-employment-based spending by the individual,
the  credit  shall  be  available for and limited to spending for health
coverage (not out-of-pocket health spending). The credit shall be avail-
able without regard to how little is spent or how  sparse  the  benefit.
The  credit may only be taken against the payroll tax. Any excess amount
may not be applied to other tax liability. The credit shall be  distrib-
uted  between  the  employer  and employee in the same proportion as the
spending by each for the benefit and may be applied to their  respective
portion  of  the  tax.  (C) If any provision of this subparagraph or any
application of it shall be ruled to violate federal ERISA, the provision
or the application of it shall be null and void and the ruling shall not
affect any other provision or application of this  section  or  the  act
that enacted it.
  3.  (a)  The  revenue  proposal  shall  include a plan and legislative
provisions  for  ending  the  requirement  for  local  social   services
districts  to  pay  part  of  the  cost  of Medicaid and replacing those
payments with revenue from the taxes under the revenue proposal.
  (b) The taxes under this section shall not supplant  the  spending  of
other  state  revenue to pay for the Medicaid program as it exists as of
the enactment of the revenue proposal as  amended,  unless  the  revenue
proposal as amended provides otherwise.
  4.  To  the extent that the revenue proposal differs from the terms of
subdivision two or paragraph (b) of subdivision three of  this  section,
the  revenue  proposal  shall  state how it differs from those terms and
reasons for and the effects of the differences.
  5. All revenue from the taxes shall  be  deposited  in  the  New  York
Health trust fund account under section 89-i of the state finance law.
  §  5.   Article 49 of the public health law is amended by adding a new
title 3 to read as follows:
                                TITLE III
          COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH
                             NEW YORK HEALTH
SECTION 4920. DEFINITIONS.
        4921. COLLECTIVE NEGOTIATION AUTHORIZED.
        4922. COLLECTIVE NEGOTIATION REQUIREMENTS.
        4923. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE.
        4924. CERTAIN COLLECTIVE ACTION PROHIBITED.
        4925. FEES.
        4926. CONFIDENTIALITY.
        4927. SEVERABILITY AND CONSTRUCTION.
  § 4920. DEFINITIONS. FOR PURPOSES OF THIS TITLE:
  1. "NEW YORK HEALTH" MEANS THE PROGRAM UNDER ARTICLE FIFTY-ONE OF THIS
CHAPTER.
  2. "PERSON" MEANS AN  INDIVIDUAL,  ASSOCIATION,  CORPORATION,  OR  ANY
OTHER LEGAL ENTITY.
  3. "HEALTH CARE PROVIDERS' REPRESENTATIVE" MEANS A THIRD PARTY THAT IS
AUTHORIZED  BY  HEALTH  CARE PROVIDERS TO NEGOTIATE ON THEIR BEHALF WITH
NEW YORK HEALTH OVER TERMS AND CONDITIONS AFFECTING  THOSE  HEALTH  CARE
PROVIDERS.

A. 4738--A                         20

  4. "STRIKE" MEANS A WORK STOPPAGE IN PART OR IN WHOLE, DIRECT OR INDI-
RECT,  BY  A  BODY OF WORKERS TO GAIN COMPLIANCE WITH DEMANDS MADE ON AN
EMPLOYER.
  5.  "HEALTH  CARE PROVIDER" MEANS A PERSON WHO IS LICENSED, CERTIFIED,
REGISTERED OR AUTHORIZED TO PRACTICE A HEALTH CARE  PROFESSION  PURSUANT
TO TITLE EIGHT OF THE EDUCATION LAW AND WHO PRACTICES THAT PROFESSION AS
A  HEALTH CARE PROVIDER AS AN INDEPENDENT CONTRACTOR OR WHO IS AN OWNER,
OFFICER, SHAREHOLDER, OR PROPRIETOR OF A HEALTH  CARE  PROVIDER;  OR  AN
ENTITY  THAT EMPLOYS OR UTILIZES HEALTH CARE PROVIDERS TO PROVIDE HEALTH
CARE SERVICES, INCLUDING BUT NOT LIMITED TO A  HOSPITAL  LICENSED  UNDER
ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR AN ACCOUNTABLE CARE ORGANIZATION
UNDER  ARTICLE  TWENTY-NINE-E  OF  THIS  CHAPTER. A HEALTH CARE PROVIDER
UNDER TITLE EIGHT OF THE EDUCATION LAW WHO PRACTICES AS AN  EMPLOYEE  OR
INDEPENDENT  CONTRACTOR  OF  ANOTHER  HEALTH  CARE PROVIDER SHALL NOT BE
DEEMED A HEALTH CARE PROVIDER FOR PURPOSES OF THIS TITLE.
  § 4921. COLLECTIVE NEGOTIATION AUTHORIZED. 1.  HEALTH  CARE  PROVIDERS
MAY  MEET  AND  COMMUNICATE  FOR THE PURPOSE OF COLLECTIVELY NEGOTIATING
WITH NEW YORK HEALTH ON ANY MATTER RELATING TO NEW YORK HEALTH,  INCLUD-
ING BUT NOT LIMITED TO RATES OF PAYMENT AND PAYMENT METHODOLOGIES.
  2. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW OR AUTHORIZE AN
ALTERATION  OF  THE TERMS OF THE INTERNAL AND EXTERNAL REVIEW PROCEDURES
SET FORTH IN LAW.
  3. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW A STRIKE OF NEW
YORK HEALTH BY HEALTH CARE PROVIDERS.
  4. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO  ALLOW  OR  AUTHORIZE
TERMS OR CONDITIONS WHICH WOULD IMPEDE THE ABILITY OF NEW YORK HEALTH TO
OBTAIN  OR  RETAIN  ACCREDITATION  BY THE NATIONAL COMMITTEE FOR QUALITY
ASSURANCE OR A SIMILAR BODY OR TO COMPLY WITH APPLICABLE STATE OR FEDER-
AL LAW.
  § 4922. COLLECTIVE NEGOTIATION REQUIREMENTS. 1. COLLECTIVE NEGOTIATION
RIGHTS GRANTED BY THIS TITLE MUST CONFORM TO THE FOLLOWING REQUIREMENTS:
  (A) HEALTH CARE PROVIDERS  MAY  COMMUNICATE  WITH  OTHER  HEALTH  CARE
PROVIDERS  REGARDING  THE TERMS AND CONDITIONS TO BE NEGOTIATED WITH NEW
YORK HEALTH;
  (B) HEALTH CARE PROVIDERS MAY COMMUNICATE WITH HEALTH CARE  PROVIDERS'
REPRESENTATIVES;
  (C)  A HEALTH CARE PROVIDERS' REPRESENTATIVE IS THE ONLY PARTY AUTHOR-
IZED TO NEGOTIATE WITH NEW YORK HEALTH ON  BEHALF  OF  THE  HEALTH  CARE
PROVIDERS AS A GROUP;
  (D)  A  HEALTH  CARE PROVIDER CAN BE BOUND BY THE TERMS AND CONDITIONS
NEGOTIATED BY THE HEALTH CARE PROVIDERS' REPRESENTATIVES; AND
  (E) IN COMMUNICATING OR NEGOTIATING WITH THE  HEALTH  CARE  PROVIDERS'
REPRESENTATIVE, NEW YORK HEALTH IS ENTITLED TO OFFER AND PROVIDE DIFFER-
ENT TERMS AND CONDITIONS TO INDIVIDUAL COMPETING HEALTH CARE PROVIDERS.
  2.  NOTHING  IN THIS TITLE SHALL AFFECT OR LIMIT THE RIGHT OF A HEALTH
CARE PROVIDER OR GROUP OF HEALTH CARE PROVIDERS TO COLLECTIVELY PETITION
A GOVERNMENT ENTITY FOR A CHANGE IN A LAW, RULE, OR REGULATION.
  3. NOTHING IN THIS TITLE SHALL AFFECT OR LIMIT  COLLECTIVE  ACTION  OR
COLLECTIVE  BARGAINING  ON THE PART OF ANY HEALTH CARE PROVIDER WITH HIS
OR HER EMPLOYER OR ANY OTHER  LAWFUL  COLLECTIVE  ACTION  OR  COLLECTIVE
BARGAINING.
  § 4923. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE. BEFORE
ENGAGING  IN  COLLECTIVE  NEGOTIATIONS WITH NEW YORK HEALTH ON BEHALF OF
HEALTH CARE PROVIDERS, A HEALTH  CARE  PROVIDERS'  REPRESENTATIVE  SHALL
FILE  WITH THE COMMISSIONER, IN THE MANNER PRESCRIBED BY THE COMMISSION-
ER, INFORMATION IDENTIFYING  THE  REPRESENTATIVE,  THE  REPRESENTATIVE'S

A. 4738--A                         21

PLAN OF OPERATION, AND THE REPRESENTATIVE'S PROCEDURES TO ENSURE COMPLI-
ANCE WITH THIS TITLE.
  §  4924.  CERTAIN  COLLECTIVE  ACTION PROHIBITED. 1. THIS TITLE IS NOT
INTENDED TO AUTHORIZE COMPETING HEALTH CARE PROVIDERS TO ACT IN  CONCERT
IN  RESPONSE TO A HEALTH CARE PROVIDERS' REPRESENTATIVE'S DISCUSSIONS OR
NEGOTIATIONS WITH NEW YORK HEALTH EXCEPT AS AUTHORIZED BY OTHER LAW.
  2. NO HEALTH CARE PROVIDERS' REPRESENTATIVE SHALL NEGOTIATE ANY AGREE-
MENT THAT EXCLUDES, LIMITS THE PARTICIPATION  OR  REIMBURSEMENT  OF,  OR
OTHERWISE LIMITS THE SCOPE OF SERVICES TO BE PROVIDED BY ANY HEALTH CARE
PROVIDER  OR GROUP OF HEALTH CARE PROVIDERS WITH RESPECT TO THE PERFORM-
ANCE OF SERVICES THAT ARE WITHIN THE HEALTH CARE PROVIDER'S LAWFUL SCOPE
OR TERMS OF PRACTICE, LICENSE, REGISTRATION, OR CERTIFICATE.
  § 4925. FEES. EACH PERSON WHO ACTS AS THE REPRESENTATIVE OF  NEGOTIAT-
ING PARTIES UNDER THIS TITLE SHALL PAY TO THE DEPARTMENT A FEE TO ACT AS
A  REPRESENTATIVE.  THE  COMMISSIONER,  BY REGULATION, SHALL SET FEES IN
AMOUNTS DEEMED REASONABLE AND NECESSARY TO COVER THE COSTS  INCURRED  BY
THE DEPARTMENT IN ADMINISTERING THIS TITLE.
  § 4926. CONFIDENTIALITY. ALL REPORTS AND OTHER INFORMATION REQUIRED TO
BE  REPORTED  TO THE DEPARTMENT UNDER THIS TITLE SHALL NOT BE SUBJECT TO
DISCLOSURE UNDER ARTICLE SIX OF THE PUBLIC OFFICERS LAW.
  § 4927. SEVERABILITY AND CONSTRUCTION. IF ANY PROVISION OR APPLICATION
OF THIS TITLE SHALL BE HELD TO BE INVALID, OR TO VIOLATE  OR  BE  INCON-
SISTENT  WITH  ANY  APPLICABLE FEDERAL LAW OR REGULATION, THAT SHALL NOT
AFFECT OTHER PROVISIONS OR APPLICATIONS OF THIS TITLE WHICH CAN BE GIVEN
EFFECT WITHOUT THAT PROVISION OR  APPLICATION;  AND  TO  THAT  END,  THE
PROVISIONS  AND APPLICATIONS OF THIS TITLE ARE SEVERABLE. THE PROVISIONS
OF THIS TITLE SHALL  BE  LIBERALLY  CONSTRUED  TO  GIVE  EFFECT  TO  THE
PURPOSES THEREOF.
  §  6.  Subdivision  11  of  section  270  of the public health law, as
amended by section 2-a of part C of chapter 58 of the laws of  2008,  is
amended to read as follows:
  11.  "State  public  health plan" means the medical assistance program
established by title eleven of article five of the social  services  law
(referred  to in this article as "Medicaid"), the elderly pharmaceutical
insurance coverage program established by title three of article two  of
the  elder  law (referred to in this article as "EPIC"), and the [family
health plus program established by section three  hundred  sixty-nine-ee
of  the social services law to the extent that section provides that the
program shall be subject to this article] NEW YORK HEALTH PROGRAM ESTAB-
LISHED BY ARTICLE FIFTY-ONE OF THIS CHAPTER.
  § 7. The state finance law is amended by adding a new section 89-i  to
read as follows:
  §  89-I. NEW YORK HEALTH TRUST FUND. 1. THERE IS HEREBY ESTABLISHED IN
THE JOINT CUSTODY OF THE STATE COMPTROLLER AND THE COMMISSIONER OF TAXA-
TION AND FINANCE A SPECIAL REVENUE FUND TO BE KNOWN  AS  THE  "NEW  YORK
HEALTH TRUST FUND", REFERRED TO IN THIS SECTION AS "THE FUND". THE DEFI-
NITIONS  IN  SECTION  FIFTY-ONE  HUNDRED  OF THE PUBLIC HEALTH LAW SHALL
APPLY TO THIS SECTION.
  2. THE FUND SHALL CONSIST OF:
  (A) ALL MONIES OBTAINED FROM TAXES PURSUANT TO LEGISLATION ENACTED  AS
PROPOSED UNDER SECTION THREE OF THE NEW YORK HEALTH ACT;
  (B)  FEDERAL  PAYMENTS  RECEIVED  AS  A  RESULT OF ANY WAIVER OR OTHER
ARRANGEMENTS AGREED TO BY THE UNITED  STATES  SECRETARY  OF  HEALTH  AND
HUMAN  SERVICES  OR  OTHER APPROPRIATE FEDERAL OFFICIALS FOR HEALTH CARE
PROGRAMS ESTABLISHED UNDER MEDICARE, ANY FEDERALLY-MATCHED PUBLIC HEALTH
PROGRAM, OR THE AFFORDABLE CARE ACT;

A. 4738--A                         22

  (C) THE AMOUNTS PAID BY THE DEPARTMENT OF HEALTH THAT  ARE  EQUIVALENT
TO  THOSE  AMOUNTS  THAT  ARE  PAID ON BEHALF OF RESIDENTS OF THIS STATE
UNDER MEDICARE, ANY FEDERALLY-MATCHED  PUBLIC  HEALTH  PROGRAM,  OR  THE
AFFORDABLE  CARE  ACT FOR HEALTH BENEFITS WHICH ARE EQUIVALENT TO HEALTH
BENEFITS COVERED UNDER NEW YORK HEALTH;
  (D)  FEDERAL AND STATE FUNDS FOR PURPOSES OF THE PROVISION OF SERVICES
AUTHORIZED UNDER TITLE XX OF THE FEDERAL SOCIAL SECURITY ACT THAT  WOULD
OTHERWISE  BE  COVERED UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW;
AND
  (E) STATE MONIES THAT WOULD OTHERWISE BE APPROPRIATED TO  ANY  GOVERN-
MENTAL  AGENCY,  OFFICE,  PROGRAM,  INSTRUMENTALITY OR INSTITUTION WHICH
PROVIDES HEALTH SERVICES, FOR SERVICES AND BENEFITS  COVERED  UNDER  NEW
YORK HEALTH. PAYMENTS TO THE FUND PURSUANT TO THIS PARAGRAPH SHALL BE IN
AN  AMOUNT  EQUAL  TO  THE  MONEY  APPROPRIATED FOR SUCH PURPOSES IN THE
FISCAL YEAR BEGINNING IMMEDIATELY PRECEDING THE EFFECTIVE  DATE  OF  THE
NEW YORK HEALTH ACT.
  3.  MONIES  IN  THE  FUND  SHALL ONLY BE USED FOR PURPOSES ESTABLISHED
UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW.
  § 8. Temporary commission on implementation. 1. There is hereby estab-
lished a temporary commission on implementation of the New  York  Health
program,  referred  to  in this section as the commission, consisting of
fifteen members: five members, including the chair, shall  be  appointed
by the governor; four members shall be appointed by the temporary presi-
dent of the senate, one member shall be appointed by the senate minority
leader;  four members shall be appointed by the speaker of the assembly,
and one member shall be appointed by the assembly minority  leader.  The
commissioner  of  health,  the superintendent of financial services, and
the commissioner of taxation and finance, or their designees shall serve
as non-voting ex-officio members of the commission.
  2. Members of the commission shall receive such assistance as  may  be
necessary  from  other  state  agencies  and entities, and shall receive
reasonable and necessary expenses incurred in the performance  of  their
duties.  The  commission  may  employ  staff  as needed, prescribe their
duties, and fix their compensation within amounts appropriated  for  the
commission.
  3.  The commission shall examine the laws and regulations of the state
and make such recommendations as are necessary to conform the  laws  and
regulations  of the state and article 51 of the public health law estab-
lishing the New York Health program and other provisions of law relating
to the New York  Health  program,  and  to  improve  and  implement  the
program. The commission shall report its recommendations to the governor
and the legislature.  The commission shall immediately begin development
of  proposals consistent with the principles of article 51 of the public
health law  for  provision  of  long-term  care  coverage;  health  care
services  covered under the workers' compensation law; and incorporation
of retiree health benefits, as described in paragraphs (a), (b) and  (c)
of  subdivision 8 of section 5102 of the public health law.  The commis-
sion shall provide its work product and assistance to the  board  estab-
lished pursuant to section 5102 of the public health law upon completion
of the appointment of the board.
  §  9.  Severability. If any provision or application of this act shall
be held to be invalid, or to violate or be inconsistent with any  appli-
cable  federal law or regulation, that shall not affect other provisions
or applications of this act which  can  be  given  effect  without  that
provision  or  application; and to that end, the provisions and applica-
tions of this act are severable.

A. 4738--A                         23

  § 10. This act shall take effect immediately.